Final Report of The Court Appointed Expert: Lippert vs. Godinez

Case: 1:10-cv-04603 Document #: 339 Filed: 05/19/15 Page 1 of 405 PageID #:3155
Final Report of the Court Appointed Expert

Lippert v. Godinez
December 2014
Prepared by the Medical Investigation Team

Ron Shansky, MD
Karen Saylor, MD
Larry Hewitt, RN
Karl Meyer, DDS
Contents
Introduction...........................................................................................................................3
Le ad e rs hipand Staffing.......................................................................................................5
ID O C O ffic
e ofH e althSe rvic
e s StaffingR e c
om m e nd ations .............................................10
Overview of Major Services................................................................................................10
C linicSpac
e and Sanitation...............................................................................................10
R ec
e ption..........................................................................................................................12
Intras ys te m T rans fe r..........................................................................................................14
M e d ic
alR e c
ord s ................................................................................................................15
N u rs ingSic
k C all..............................................................................................................16
C hronicD ise as e M anage m e nt ...........................................................................................19
P harm ac
y/M e d ic
ation A d m inistration ...............................................................................23
Laboratory.........................................................................................................................24
U ns c
he d u le d O ns ite and O ffs ite Se rvic
e s (U rge nt/E m e rge nt)............................................25
Sc
he d u le d O ffs ite Se rvic
e s (C ons u ltations and P roc
e d u re s )...............................................28
Infirm ary ...........................................................................................................................32
Infe c
tion C ontrol...............................................................................................................34
D e ntalP rogram .................................................................................................................38
M ortality R e views .............................................................................................................42
C ontinu ou s Q u ality Im prove m e nt......................................................................................43
Conclusions..........................................................................................................................45
Introduction
T oward s the e nd of2013, D r. R onald Shans ky was nom inate d by the parties and appointe d by
the c
ou rt in the Lippe rt m atte r as an e xpe rt pu rs u ant to R u le 706 of the Fe d e ral R u le s of
E vid e nc
e . T he ord e rappointinghim lays ou t the s c
ope ofthe d u ties .
T he e xpe rt willas s ist the c
ou rt in d e te rm iningwhe the rthe Illinois D e partm e nt of
C orre c
tions (ID O C ) is provid ing he alth c
are s e rvic
e to the offe nd e rs in its
c
u s tod y that m e e t the m inim u m c
ons titu tionals tand ard s ofad e qu ac
y.
It fu rthe r goe s on to s ay that the e xpe rt willinve s tigate allre le vant c
om pone nts of the he alth
c
are s ys te m e xc
e pt for program s e rvic
e s and protoc
ols that re late e xc
lu s ive ly to m e ntalhe alth.
Fu rthe rm ore ,
If s ys te m icd e fic
ienc
ies in ID O C he alth c
are are ide ntified he will propos e
s olu tions forc
ons ide ration by the parties and the c
ou rt. T he s e propos e d s olu tions ,
ifany, willform the bas e s for fu tu re ne gotiations be twe e n the parties in an e ffort
to c
raft a final s e ttle m e nt of this m atter or alte rnative ly, m ay be offe re d into
e vid e nc
e in the trialof this m atter. Fu rthe rm ore , the e xpe rt willnot re c
om m e nd
s pe c
ifictre atm e nt forind ivid u aloffe nd e rs u nle s s thos e re c
om m e nd ations re late to
s ys te m icd e fic
ienc
ies in the he althc
are provid e d to offe nd e rs in ID O C c
u s tod y.
T he parties have als o ac
c
e pte d K are n Saylor, M .D ., Larry H e witt, R .N . and K arlM e ye r, D .D .S.
as ad d itionalte am m e m be rs . T he e xpe rt m e t with the parties in late 2013 and as e c
ond tim e in
A prilof2014. T he firs t m e e tingfoc
u s e d on the m e thod ology to be u s e d as we llas qu e s tions that
e ithe r of the parties had with re gard to the proc
e s s . T he A pril m e e tingwas inte nd e d to be an
u pd ate , havingvisite d by that tim e approxim ate ly halfofthe fac
ilities to be re viewe d . T he e xpe rt
thou ght this wou ld be valu able be c
au s e the c
onfid e ntiald raft re port was not d u e u ntilthe s ite
visits and m ortality re views had be e n c
om ple te d and the re fore the re wou ld have be e n no
opportu nity to jointly u pd ate the parties u ntilthe y ac
tu ally re c
e ive d the c
onfid e ntiald raft re port.
B oth parties have be e n e xtre m e ly s u pportive of this proc
e s s . W e re c
e ive d fu ll c
oope ration at
e ac
hofthe prisons we visite d and are e xtre m e ly appre c
iative ofthe loc
ale fforts to fac
ilitate the
proc
ess.
T he inve s tigative te am was as s igne d an e xplic
it tas k, T o as s ist the C ou rt in d e te rm iningwhe the r
the s tate of Illinois was able to m e e t m inim al c
ons titu tional s tand ard s with re gard to the
ad e qu ac
y of its he alth c
are program for the popu lation it s e rve s . In ord e r to re ac
h this
c
onc
lu s ion, the parties d e te rm ine d that we s hou ld visit at le as t e ight fac
ilities , s ix ofwhic
hwe re
jointly s e le c
te d by the parties . T he inve s tigative te am c
onc
u rs withthe parties s e le c
tions , in that
thos e s ix fac
ilities have s pe c
ial re s pons ibilities within the s ys te m and are c
ritic
al to a
d e te rm ination as to whe the r, whe n the he althc
are s ys te m s are m os t c
halle nge d , the y are able to
ad e qu ate ly m e e t that c
halle nge . T hre e of the ins titu tions re viewe d fu nc
tione d as re c
e ption
c
e nte rs . T he s e fac
ilities are c
ritic
alin that the y pe rform the initiale valu ation u pon e ntry into the
s ys te m . P roble m s that the y failto ide ntify are m u c
h m ore like ly to e ithe r not be ad d re s s e d or
s om e tim e s at am inim u m , the id e ntific
ation and the inte rve ntions are s ignific
antly d e laye d . T hre e
fac
ilities we re m axim u m -s e c
u rity fac
ilities whic
hhou s e the m os t c
halle ngingofpopu lations for
3
whic
h to provide he alth c
are s e rvic
e s . Finally, one of the s ix hou s e s the s ys te m
s s pe c
ial
ge riatric
s u nit, whic
hals o c
re ate s he althc
are c
halle nge s . It has be e n ou re xpe rienc
e that whe n a
s ys te m is able to m e e t c
ons titu tionals tand ard s at the m os t c
halle nge d ins titu tions , it is ve ry like ly
to m e e t c
ons titu tionals tand ard s at the le s s c
halle ngingfac
ilities . T he c
onve rs e , howe ve r, in ou r
e xpe rienc
e has not prove n to be tru e .
T he State ind ic
ate s that the inve s tigation te am s hou ld have u tilize d s tand ard s s u c
h as the
N ationalC om m iss ion on C orre c
tionalH e althC are orthe A m e ric
an C orre c
tionalA s s oc
iation as
the bas is for both ou r inve s tigation and ou r re c
om m e nd ations . T he le ad e r of the inve s tigative
te am s e rve d on the board ofthe N ationalC om m iss ion on C orre c
tionalH e althC are for10ye ars .
H e has als o be e n involve d withthe d e ve lopm e nt ofthe s tand ard s forthe las t 20ye ars , s e rvingon
thre e of the tas k forc
e s and ad visingthe m os t rec
e nt tas k forc
e . In ad d ition, he has als o be e n
re qu e s te d and has provid e d trainingto allof the N C C H C s u rve yors with re gard to the qu ality
im prove m e nt s tand ard and how to s u rve y it. H e him s e lfhas d one s u rve ys in e ac
hofthe las t thre e
ye ars . A llof the m e m be rs of the inve s tigative te am be lieve that the N ational C om m iss ion on
C orre c
tional H e alth C are , throu gh its s tand ard s , its s u rve ys and its training, have c
ontribu te d
s u bs tantially ove rthe pas t thre e to fou rd e c
ad e s in he lpingfac
ilities im prove the qu ality ofhe alth
c
are . W he n the s u rve y proc
e s s oc
c
u rs , abou t 80% of that proc
e s s is foc
u s e d on ad m inistrative
m atte rs ;polic
ies , proc
e d u re s , c
ontrac
ts and othe rad m inistrative m atte rs . A pproxim ate ly 20% of
the s u rve y proc
e s s is foc
u s e d on c
linic
alc
are , and d u ringthat proc
e s s the le ad inve s tigator has
re c
e ntly be e n as ke d to he lp re d e s ign the m e thod ology u s e d to as s e s s c
are iss u e s . Inve s tigations
that are part of litigation and as s ist the c
ou rt in d e te rm iningwhe the r and the e xte nt to whic
h
d e libe rate ind iffe re nc
e to s e riou s m e d ic
al ne e d s m ay e xist re qu ire s that the foc
u s be
ove rwhe lm ingly on c
linic
alc
are iss u e s . T hu s , virtu ally allofthe tim e that we s pe nt, othe r than
u nd e rs tand ing how s e rvic
e s are provid e d at e ac
h fac
ility, d e alt with inte rviewing s taff and
inm ate s , obs e rvingproc
e s s e s and re viewingm e d ic
al re c
ord s . For the pu rpos e s of the c
ou rt,
c
linic
al c
are is of ove rwhe lm ingim portanc
e and ad m inistrative iss u e s , thou gh im portant, are
m uc
h, m u c
hle s s im portant.
A re c
e nt artic
le by A le x Fried m ann pu blishe d in Prison Legal News, O c
tobe r 2014, d e s c
ribe s
withs pe c
ificc
itations abou t how the c
ou rts view s pe c
ific
ally A C A ac
c
re d itation, bu t als o how
the c
ou rts view ac
c
re d itation in ge ne ral. M ore c
om m only the c
ou rts have s aid that the y d o not
re ly in the ir d e te rm inations ofc
ons titu tionality on the pre s e nc
e or abs e nc
e ofac
c
re d itation. W e
be lieve that this is bas e d on the fac
t that the foc
u s in c
ons titu tionald ispu te s is ove rwhe lm ingly
on c
linic
alc
are m atte rs , whe re as in ac
c
re d itation the foc
u s is ove rwhe lm ingly on ad m inistrative
iss u e s . T he word ingof the c
ons titu tional d e finition of an E ight A m e nd m e nt violation forc
es
inve s tigators , whe the r the y be plaintiffs or d e fe nd ants or workingfor both parties , to he avily
foc
u s on c
linic
alc
are iss u e s . H avings aid this is not m e ant in any way to d im inishthe valu e of
the ac
c
re d itation proc
e s s , s pe c
ific
ally with the N ational C om m iss ion on C orre c
tional H e alth
C are .
H avingre c
e ive d the c
om m e nts from both plaintiffs and d e fe nd ants , it has be e n ac
halle nge to
inte grate s om e ofthe c
om m e nts into the finald raft. T he State has ind ic
ate d it has d one s e ve ral
things whic
h are c
ons iste nt with the inve s tigative te am
s re c
om m e nd ation. Sinc
e we c
annot
ve rify whe re things are in the proc
e s s , we are not ad d re s s ingthos e things in the final re port.
R athe r, any of the u pd ate s will be available to the C ou rt in an appe nd ix whic
h inc
lu d e s both
4
plaintiff
s and d e fe nd ant
s re s pons e s . O n the othe rhand , whe re the re are c
larific
ations re qu e s te d
or alte rnative s propos e d , we have atte m pte d to be re s pons ive . In s om e ins tanc
e s , the original
paragraphs we fe e lwe re c
le ar e nou gh;in othe r ins tanc
e s , we have m od ified the originald raft.
W e fe e lwe have m ad e as inc
e re e ffort to be re s pons ive to the parties .
In ord e r to pe rform s u c
hare view, it is ne c
e s s ary to u tilize avariety of inve s tigative s trate gies .
W e inte rviewe d s taff, we have inte rviewe d inm ate s , we have obs e rve d c
are provid e d , we have
re viewe d polic
ies and proc
e d u re s and c
om pare d prac
tic
e to the polic
ies and proc
e d u re s , we have
re viewe d m inu te s of m e e tings and we have re viewe d s e le c
te d re c
ord s , inc
lu d ingd e athre c
ord s .
In ord e rto be s t d e s c
ribe ac
orre c
tionalhe althc
are program , we have fou nd it u s e fu lto organize
the ins titu tionalre views alongthe line s ofm ajors e rvic
e s provide d . T his listingofs e rvic
e s is not
e xhau s tive ; howe ve r, it e nable s a fairly c
om pre he ns ive s naps hot of how the program is
fu nc
tioning. T he c
ritic
als e rvic
e s be gin with m e d ic
alre c
e ption, whic
h is d e s igne d to c
re ate an
aware ne s s and u nd e rs tand ingofthe m e d ic
alne e d s ofpatients on e ntry to the s ys te m . W e visite d
thre e re c
e ption c
e nte rs ;the m ain re c
e ption c
e nte r, whic
h is the N orthe rn R e c
e ption C e nte r,
whic
h re c
e ive s inm ate s from C ook C ou nty;the re c
e ption proc
e s s at the Logan C orre c
tional
C e nte r, the m ajorwom e n
s prison;and the M e nard C orre c
tionalC e nte r, whic
hre c
e ive s farfe we r
ne w inm ate s , e s pe c
ially thos e from Sou the rn Illinois. A n ad ju nc
t to the re c
e ption proc
e s s for
whe n patients are trans fe rre d from one fac
ility to anothe r is the intras ys te m trans fe r proc
ess.
B othre c
e ption and intras ys te m trans fe r proc
e s s e s are d e s igne d to ide ntify proble m s and ins u re
c
ontinu ity ofc
are d e s pite the pote ntiald isru ption d u ringatrans fe r. O the rm ajors e rvic
e s inc
lu d e
nu rs e and provide r s ic
k c
all (prim ary c
are s e rvic
e s ), c
hronic c
are s e rvic
e s , m e d ic
ation
m anage m e nt s e rvic
es, sc
he d u le d offs ite s e rvices (s pe c
ialty c
ons u ltations and proc
e d u re s ),
u ns c
he d u le d ons ite and offs ite s e rvic
e s (u rge nt/e m e rge nt re s pons e s ), infirm ary s e rvic
e s (ons ite
inpatient c
are ), infe c
tion c
ontrols e rvic
e s and d e ntals e rvic
e s . A llof the s e m ajor s e rvic
e are as
m u s t be s u pporte d by an e ffe c
tive qu ality im prove m e nt program that not only s e lf-m onitors bu t
als o e ffe c
tive ly id e ntifies pe rform anc
e im prove m e nt ne e d s and im ple m e nts s trate gies that
fac
ilitate pe rform anc
e im prove m e nt. It is the s e s e rvic
e s for whic
hwe willprovid e an ove rview
in this c
onfid e ntiald raft re port and forwhic
hwe willattac
hins titu tionalappe nd ic
e s in whic
hou r
s pe c
ificfind ings within e ac
hins titu tion are d e taile d . Finally, the re port inc
lu d e s are view of63
d e aths by D r. Saylor and D r. Joe Gold e ns on, who was ad d e d to the te am withthe agre e m e nt of
the parties in ord e rto fac
ilitate c
om ple tion ofthe m ortality re views . In ord e rto d isc
u s s s e rvic
es,
we are forc
e d to ad d re s s bothle ad e rs hipiss u e s as we llas s taffingiss u e s , and the d e gre e to whic
h
le ad e rs hip or s taffingwe re s ignific
antly proble m aticvaries by ins titu tion. In the ins titu tional
appe nd ic
e s , we d e s c
ribe s hortc
om ings in s om e d e tail.
Leadership and Staffing

Le ad e rs hipis aproble m at virtu ally allofthe fac
ilities we visite d . T he qu e s tion varied only with
re gard to d e gre e. T he re as on why le ad e rs hip is s o im portant to ac
orre c
tionalhe althprogram is
be c
au s e the y are re s pons ible for s e ttingthe tone withre gard to boths tru c
tu re and profe s s ional
pe rform anc
e as we llas ins u ringthat the program e ffe c
tive ly s e lf-m onitors and s e lf-c
orre c
ts so
that proble m s are id e ntified , ad d re s s e d and u ltim ate ly e lim inate d . T hrou gh this s e lf-c
orre c
ting
proc
e s s pote ntial harm to patients is c
ontinu ally m itigate d . W ithou t a strong and e ffe c
tive
le ad e rs hip te am aprogram is m u c
hle s s able to id e ntify the c
au s e s ofs ys te m icproble m s and to
e ffe c
tive ly ad d re s s thos e proble m s by im ple m e nting appropriate targete d im prove m e nt
5
s trate gies . A t the e xtre m e was D ixon, as pe c

ialm iss ion (re c
e ption c
e nte r, ge riatricu nit, s pe c
ial
program for d isable d , s pe c
ial hou s ing for patients with m e d ic
al or m e ntal he alth proble m s )
fac
ility, bothm e d ic
aland m e ntalhe alth, whic
hat the tim e ofou rvisit had avac
ant H e althC are
U nit A d m inistrator pos ition, a vac
ant D ire c
tor of N u rs ingpos ition and in e s s e nc
e a vac
ant
M e d ic
al D ire c
tor pos ition fille d by a W e xford trave llingm e d ic
al d ire c
tor. Spe c
ial m iss ion
fac
ilities s e rve a fu nc
tion for the e ntire prison s ys te m and thu s te nd to c
onc
e ntrate m e d ic
al
pathology or proble m s . A s are s u lt ofthe c
onc
e ntration of m e d ic
alproble m s , aprogram that is
not e ffe c
tive ly m anage d c
re ate s the pote ntialfor harm to the patients and le gal liability to the
State. T he d e gre e of bre akd owns we fou nd at D ixon we re the m os t s e ve re . T he re m u s t be a
re qu ire m e nt that aM e d ic
alD ire c
tor hire d by W e xford m u s t be board c
e rtified in prim ary c
are ,
pre fe rably e ithe r fam ily m e d ic
ine or inte rnal m e d ic
ine . In ad d ition, the one H e alth C are
A d m inistrator re s pons ible for both N R C and State ville had be e n takinge xte nd e d le ave s of
abs e nc
e . T his is a ve hic
le for failu re . A d d itionally, the D ire c
tor of N u rs ingpos ition at e ac
h
fac
ility, c
om m only a ve nd or pos ition, m u s t have the re s pons ibility on a fu ll-tim e bas is for
ove rs e e ingnu rs ingc
linic
al s e rvic
e s . W e are told that at s e ve ral s ite s the y have an ad d itional
ad m inistrative as s ignm e nt with re gard to W e xford c
orporate re s pons ibilities . T his is not
ac
c
e ptable . T he ove rs ight ofas u bs tantialnu rs ingprogram is afu ll-tim e job. N o tim e s hou ld be
take n away from that re s pons ibility. T he le ad e rs hipvac
u u m s at D ixon, State ville and N R C have
re s u lte d in proc
e s s and c
are bre akd owns on a d aily bas is. R e c
e ption is not d one tim e ly and
m e d ic
alre c
ord s are alm os t im pos s ible to e ffe c
tive ly u tilize at N R C d e s pite the fac
t that the re is a
pe rs on ons ite in c
harge ofm e d ic
alre c
ord s . A t Illinois R ive r, the M e d ic
alD ire c
tor pos ition was
vac
ant and this was be ingfille d two d ays pe r we e k by the M e d ic
alD ire c
tor from E as t M oline .
T he re appe are d to be an e ffe c
tive D ire c
torofN u rs ingwho atte m pte d to fillin als o as the H e alth
C are U nit A d m inistrator, s inc
e that pos ition was fille d by s om e one on m ilitary le ave forthe pas t
ye ar and ahalf. A t H illC orre c
tionalC e nte r, both the H e alth C are A d m inistrator pos ition and
D ire c
tor of N u rs ingpos ition we re fille d by ind ivid u als who appe are d to be qu ite c
apable . T he
M e d ic
alD ire c
tor pos ition is fille d by ad oc
tor for whom we id e ntified c
linic
alc
onc
e rns d u ring
ou rre c
ord re views and m ortality re views . A t M e nard , the M e d ic
alD ire c
torpos ition is fille d by a
c
linic
ian traine d as age ne rals u rge on. T his fac
ility als o has no prim ary c
are traine d c
linic
ians ,
e ve n thou ghthe ove rwhe lm ingm ajority of c
linicalre s pons ibilities fallwithin the prim ary c
are
field . T he re is no D ire c
torofN u rs ingat M e nard ;howe ve r, the H e althC are U nit A d m inistrator
appe ars qu ite c
apable and m ake s an e ffort to fillin. H owe ve r, as ind ic
ate d throu ghthis re view of
e ight ins titu tions , ve ry fe w if any withthe e xc
e ption ofP ontiachave ac
om ple te te am with all
pos itions fille d by c
apable ind ivid u als . It is not s u rprisingthat the we ake r the le ad e rs hip the
poorer the m e d ic
al pe rform anc
e . E ac
h program
s pe rform anc
e s hou ld be m e as u re d at le as t
annu ally and , whe re ind ic
ate d , le ad e rs hipc
hange s m u s t be m ad e .
W e fou nd c
linic
ian qu ality to be highly variable ac
ros s the ins titu tions we visite d and ac
ros s
m e d ic
alre c
ord s we re viewe d . T he re we re e xam ple s ofhighqu ality c
linic
ians at s om e fac
ilities ,
bu t in othe r ins tanc
e s the qu ality of c
linic
al c
are was poor and re s u lte d in avoidable harm to
patients . For e xam ple , none ofthe thre e phys ic
ians at one ins titu tion we visite d had any form al
trainingin aprim ary c
are field . D u ringthe c
ou rs e ofou r re view ofthe c
are at this fac
ility, we
c
am e ac
ros s s e ve ral e xam ple s of avoidable harm to patients re s u lting from inappropriate
m anage m e nt ofc
om m on prim ary c
are c
ond itions . For e xam ple , at M e nard , patient [REDACTED]
d e ve lope d ad iabe ticfoot u lc
e r that was not appropriate ly m anage d and re s u lte d in am pu tation.
T his s am e patient, atype 1 d iabe tic
, had his ins u lin d isc
ontinu e d in re s pons e to we llc
ontrolle d
6
blood s u gars , whic

hre s u lte d in d ram aticd e te rioration ofhis d iabe te s c
ontrol. T his e rrorre fle c
ts
alac
k ofu nd e rs tand ingofthe bas icpathophys iology ofthis c
om m on d ise as e . In anothe rins tanc
e
at this fac
ility, patient [REDACTED] pre s e nte d with poorly c
ontrolle d d iabe te s and the d oc
tor
triple d his ins u lin d os e and qu ad ru ple d the d os e ofhis oralm e d ic
ation. T his ofc
ou rs e re s u lte d in
re pe ate d e pisod e s oflow blood s u gar. Lu c
kily the patient kne w to re fu s e his m e d ic
ation in ord e r
to avoid s e riou s harm .
A t Illinois R ive r, a26-ye ar-old m an ([REDACTED])re pe ate d ly inform e d he althc
are s taffthat he
had atrial fibrillation, a fac
t that was c
onfirm e d by his jail re c
ord s , bu t this history was
d isc
ou nte d u ntilhe s u ffe re d as troke . H ad c
linic
als taff liste ne d to the patient and re viewe d his
jailre c
ord , the y wou ld have le arne d that he s hou ld have be e n on blood thinne rs to re d u c
e the
c
hanc
e s of this d e vas tatinge ve nt. A t the s am e fac
ility, P atient [REDACTED] pre s e nte d with
c
las s ics igns and s ym ptom s of lu ngc
anc
e r from the tim e he arrive d in ID O C , ye t the s e we re
ignore d by he alth c
are s taff for thre e m onths . B y the tim e he was finally d iagnos e d , the only
tre atm e nt he was e ligible forwas palliative rad iation, whic
hhe d e c
line d . H e d ied nine d ays late r.
T he hiringof u nd e rqu alified c
linic
ians into the s ys te m is proble m atic
, as e vid e nc
e d by the
e xam ple s s tate d above . B y u nd e rqu alified ,we d o not m e an that the provid e ris not qu alified to
prac
tic
e m e d ic
ine , bu t rathe r u nd e rqu alified to prac
tic
e the type of m e d ic
ine re qu ire d of the
pos ition. For e xam ple , age ne rals u rge on is u nd e rqu alified to prac
tic
e prim ary c
are in the s am e
way an inte rnist is u nd e rqu alified to prac
tic
e ge ne rals u rge ry. T his proble m is c
om pou nd e d by a
lac
k of c
linic
alove rs ight and pe e r re view, both loc
ally and c
e ntrally, and alac
k of e le c
tronic
re s ou rc
e s , whic
hpre ve nts c
linic
ians from havingac
c
e s s to inform ation vitalto m e d ic
ald e c
ision
m akingat the point of c
are . W e re c
om m e nd that allM e d ic
alD ire c
tors be board c
e rtified in a
prim ary c
are field and s taffphys ic
ians have s u c
c
e s s fu lly c
om ple te d aprim ary c
are re s id e nc
y. It
is ne c
e s s ary that allc
linic
ians have ac
c
e s s to e le c
tronice d u c
ationalre s ou rc
e s at the point ofc
are .
T his m e ans that c
om pu te rs with inte rne t ac
c
e s s s hou ld be pre s e nt in the e xam room s s o that
provide rs c
an ac
c
e s s e s s e ntialc
linic
alinform ation at the tim e the y are s e e ingthe patients . T he re
s hou ld be pe riod icpe e r re view ofc
linic
alprac
tic
e , bothat the loc
al/fac
ility le ve land c
e ntrally.
A t m os t ofthe fac
ilities we visite d , the M e d ic
alD ire c
tors we re fu nc
tioningin prim arily c
linic
al
role s and s pe nt little ifany tim e re viewingthe c
linic
alprac
tic
e ofthe othe rprovide rs ore ngaging
in othe rim portant ad m inistrative d u ties .
Staffingd e fic
ienc
ies are fac
ility s pe c
ificto Stateville and D ixon with re gard to the nu m be r of
vac
anc
ies . For e xam ple , 23 ofState ville
s 66 bu d ge te d pos itions are vac
ant, and 18 ofD ixon
s
66 bu d ge te d pos itions are vac
ant. A d d ingto the proble m is that ke y le ad e rs hip pos itions are
vac
ant at the s e two fac
ilities . State ville
s H e alth C are U nit A d m inistrator, who is als o
re s pons ible forthe N R C , has be e n on an e xte nd e d m e d ic
alle ave ofabs e nc
e . A d d e d to that is the
iss u e that 10 of the 20 bu d ge te d c
orre c
tionalnu rs e II re giste re d nu rs e pos itions are vac
ant, as
we llas 10 of the 18 bu d ge te d c
orre c
tionalm e d ic
alte c
hnic
ian pos itions . W hile this nu m be r of
vac
ant pos itions c
re ate s a s ignific
ant ope rational iss u e , the proble m be c
om e s wors e be c
au s e
State ville nu rs ings taff is re qu ire d to as s ist at the N R C with intake and ope ration of the N R C
he althc
are u nit, and State ville nu rs ings taff is re as s igne d to the N R C whe n N R C nu rs ings taff
d oe s not re port to work. T he N R C s c
he d u le E ofapprove d bu d ge te d pos itions only provid e s for
e ight pos itions , none of whic
h are nu rs ing s taff. A s a re s u lt, he alth c
are d e live ry s u ffe rs
s ignific
antly, whic
h affe c
ts ac
c
e s s to c
are and re s u lts in d e lays in tre atm e nt. Staffingat N R C
7
m u s t be s u ffic
ient to ins u re m e d ic
alintake proc
e s s ingis c
om ple te d within one we e k of e ntry.
T his willre qu ire ad d itionalc
linic
ians and pos s ibly ad d itionalnu rs ings taffand m e d ic
alre c
ord s
s taff.
O fD ixon
s 18 vac
anc
ies , thre e are ke y he althc
are u nit le ad e rs hip pos itions . A t the tim e ofou r
visit, the M e d ic
alD ire c
tor, H e alth C are U nit A d m inistrator and D ire c
tor of N u rs ingpos itions
we re allvac
ant. T he only le ad e rs hip pre s e nt in the he althc
are u nit was two s u pe rvisingnu rs e s ,
bothofwhom we re ne w to the irpos itions . O ne ofthe s u pe rvisors was e m ploye d by the State and
one by the m e d ic
alve nd or. A s are s u lt, the y e ac
hs u pe rvise d ad iffe re nt grou pofs taffwho we re
as s igne d the s am e re s pons ibilities , and e ac
hs u pe rvisorhad he rown age nd aas are s u lt ofhaving
d iffe re nt e m ploye rs . C ou ple d withthis was that s e ve n of16 bu d ge te d c
orre c
tions nu rs e I (R N )
State pos itions we re vac
ant.
T he re m ainingfac
ility vac
anc
ies (P ontiac
, Logan, IL R ive r, H ill, and M e nard )range d from nine
at M e nard to only one at H ill, with the othe r fac
ilities fallings om e whe re in be twe e n. E ve n
thou gh the ac
tu alnu m be r of vac
anc
ies was low, the re was at le as t one ke y le ad e rs hip pos iton
vac
ant at Logan (D O N ), IL R ive r(H C U A )and M e nard (D O N ).
O fad d itionalc
onc
e rn was that at s e ve ralfac
ilities m e d ic
alve nd or e m ploye e s who we re filling
ke y le ad e rs hip pos itions , s u c
h as the d ire c
tor of nu rs ing, s u pe rvisingnu rs e or m e d ic
alre c
ord s
d ire c
tor, we re as s igne d ad d itional c
orporate d u ties s u c
h as tim e -ke e ping, payroll or hu m an
re s ou rc
e s , whic
h took the m away from the ir fu ll-tim e re s pons ibilities . T he s e pos itions we re
inc
lu d e d in the s c
he d u le E of approve d bu d ge te d pos itions to provid e fu ll-tim e s e rvic
e to the
fac
ility within the irjobd e s c
ription. T akingthe m away from that u nd e rm ine s the ope ration ofthe
he althc
are u nit and program .
A t e ac
h fac
ility, as ic
kc
all s ys te m has be e n d e ve lope d and im ple m e nte d whic
h pe rm its s taff
othe r than re giste re d nu rs e s to re view/triage s ic
k c
all re qu e s ts and e valu ate /as s e s s and tre at
patients . It is ou r opinion that this type of ind e pe nd e nt as s e s s m e nt (whic
h is what anu rs e is
re qu ire d to pe rform in re s pond ingto as ic
kc
alls ym ptom c
ontainingre qu e s t)is be yond the s c
ope
of prac
tic
e for othe r than re giste re d nu rs ing s taff. T he State of Illinois N u rs e P rac
tic
e A c
t
e xc
lu s ive ly s anc
tions re giste re d nu rs e s to pe rform ind e pe nd e nt as s e s s m e nts , althou gh it d oe s
allow for lic
e ns e d prac
tic
alnu rs e s orothe rs to as s ist in pe rform ingas s e s s m e nts . T hat as s istanc
e
c
ou ld inc
lu d e takingvital s igns or as kings om e qu e s tions re gard ingthe patient
s history with
re gard to as pe c
ificproble m . W he n anu rs e pe rform s s ic
kc
all, the patient has pre s e nte d are qu e s t
foran as s e s s m e nt bas e d on one orm ore s ym ptom s . A re giste re d nu rs e has the trainingand s kills
to e lic
it an appropriate history, pe rform an appropriate phys ic
alas s e s s m e nt bas e d on the history
and the n s ynthe s ize the d atainto anu rs ingd iagnos is and are late d plan. Fre qu e ntly, s ys te m s
provide protoc
ols to aid the re giste re d nu rs e s in c
om ple tingthe s e as s e s s m e nts . T o allow s taff
who d o not m e e t the re qu ire m e nts by trainingand c
e rtific
ation ofare giste re d nu rs e to pe rform
the s e as s e s s m e nts inc
re as e s the pote ntialforharm to the patients as we llas le galliability forthe
State.
It is c
ritic
alfor the O ffic
e of H e alth Se rvic
e s to e s tablish the s pe c
ific
ations for the he alth c
are
c
ontrac
ts as we llas to m onitor and ove rs e e the pe rform anc
e of thos e c
ontrac
ts and provid e a
d ire c
tion to the field with re gard to polic
ies and proc
e d u re s as we ll as c
linic
al gu id e line s . In
8
ord erto provide s u c

hgu id anc
e the O ffic
e ofH e althSe rvic
e s re qu ire s appropriate re s ou rc
e s . N ot
only is the M e d ic
alD ire c
torpos ition c
ritic
alin provid ingc
linic
algu id anc
e bu t als o in ove rs e e ing
su c
halarge he althc
are program , the M e d ic
alD ire c
tors hou ld be provide d withre gionalm e d ic
al
d ire c
tors als o board c
are to ass ist him orhe r in provid ingc
linic
alove rs ight.
U nive rs ally we we re inform e d by bothState e m ploye d s taff as we llas s om e ve nd or e m ploye d
s taffthat the re we re s ignific
ant proble m s withthe ve nd or e m ploye d re gionalm e d ic
ald ire c
tors .
W e pe rc
e ive the trans fe r of the s e pos itions d ire c
tly to the State M e d ic
alD ire c
tor s hou ld allow
for im prove d ove rs ight and gu id anc
e . T he re c
om m e nd ations we have m ad e are in ord e r to
e lim inate the c
onflic
t ofinte re s t inhe re nt in c
orporate e m ploye d phys ic
ians re viewingthe work
of c
orporate e m ploye d phys ic
ians . A d e c
ision of te rm ination be c
om e s an e xpe ns e for the
c
orporation. T he le ad e rofthe inve s tigative te am was M e d ic
alD ire c
torin the State ofIllinois for
11 ye ars . D u ringthat tim e , we e valu ate d the pe rform anc
e ofphys ic
ians re gu larly and inform e d
ve nd ors whe n s u c
hphys ic
ians c
ou ld no longe r be e m ploye d in the State ofIllinois. W e be lieve
c
ontrac
tu al agre e m e nts c
an be c
hange d and in fac
t s hou ld be c
hange d whe n the y are in the
inte re s t ofthe State in provid ingm inim ally ad e qu ate c
ons titu tionalc
are . T his inve s tigative te am
has be e n e xtre m e ly d isappointe d in the pe rform anc
e ofthe ve nd orand the fac
ility program s with
re gard to both profe s s ional pe rform anc
e re view, m ortality re views and the e ntire qu ality
im prove m e nt program . T he re qu ire m e nt that phys ic
ians pe rform ing pe e r re views be board
c
are , whic
h is the type of s e rvic
e that the y are e valu ating, is appare nt and
ne e d s not be ju s tified .
In ad d ition, be c
au s e the qu ality im prove m e nt program ofany and allhe althc
are organizations is
so c
e ntralto the d e ve lopm e nt of an e ffe c
tive program , the c
e ntraloffic
e s hou ld have a we lltraine d qu ality im prove m e nt c
oord inator re s pons ible for d ire c
ting the s ys te m -wid e qu ality
im prove m e nt program . T his pos ition wou ld provid e trainingand c
ons u ltation to fac
ilitate for
e ac
h s ite the d e ve lopm e nt of an e ffe c
tive qu ality im prove m e nt program . A nalogou s ly, the
s tate wide infe c
tion c
ontrol c
oord inator pos ition s hou ld be re s tore d to as s ist in e d u c
atingthe
ins titu tions with re gard to infe c
tion c
ontrol as we ll as m onitoringthe pe rform anc
e of thos e
program s . T his pe rs on als o has are s pons ibility as aliaison to the State D e partm e nt ofH e alth. A ll
of the s e c
hange s s hou ld fac
ilitate re d u c
ingthe pote ntialfor harm to patients by im provingthe
ove rs ight and ability to re s pond by the State .
Recommendations:
1. A ll M e d ic
al D ire c
tors m u s t be board c
e rtified in a prim ary c
are field . T he State has
m isre ad this, ind ic
atingthat allphys ic
ians m u s t be board c
e rtified . T he inve s tigative te am
has ind ic
ate d that othe r prim ary c
are s taff phys ic
ians s hou ld have c
om ple te d an
ac
c
re d ite d re s id e nc
y trainingprogram in inte rnal m e d ic
ine or fam ily prac
tic
e and be
e ithe r board c
e rtified or be c
om e board c
e rtified within thre e ye ars ofe m ploym e nt. O nly
the State M e d ic
alD ire c
torc
ou ld grant e xc
e ptions to this re qu ire m e nt bas e d on his orhe r
own as s e s s m e nt of the c
and id ate s . T he bas is for this re c
om m e nd ation is that in ou r
e xpe rienc
e and d isc
u s s ion with othe r State M e d ic
al D ire c
tors , the re have be e n a
d isproportionate nu m be r of pre ve ntable ne gative ou tc
om e s re late d to prim ary c
are
s e rvic
e s provid e d by non-prim ary c
are traine d phys ic
ians . T he inve s tigative te am d oe s
not be lieve that e xpe rienc
e prac
tic
ingin afield withou t the re qu ire d trainingis ad e qu ate
in m itigatingthe pre ve ntable ne gative ou tc
om e s .
2. A llc
linic
ians s hou ld have ac
c
e s s to e le c
tronicm e d ic
alre fe re nc
are .
9
3. E ve ry s pe c
ialm e d ic
alm iss ion fac
ility m u s t have its own H e althC are A d m inistrator.
4. T he D ire c
torofN u rs ingpos ition at allfac
ilities is afu ll-tim e pos ition whos e tim e s hou ld
not be take n away by c
orporate re s pons ibilities .
5. E s tablishapprove d bu d ge te d pos itions for State ville and the N R C whic
hallow for e ac
h
fac
ility to fu nc
tion ind e pe nd e ntly.
6. P rovid e a fu ll-tim e H e alth C are U nit A d m inistrator as we ll as a fu ll-tim e Q u ality
Im prove m e nt C oord inator/Infe c
tion C ontrolN u rs e forbothState ville and the N R C .
7. E ac
h fac
ility is to d e ve lop and im ple m e nt a plan to ins u re re giste re d nu rs ings taff is
c
ond u c
tings ic
kc
all.
8. M e d ic
alve nd or he althc
are s taffas s igne d to le ad e rs hip pos itions , s u c
has the d ire c
torof
nu rs ing, s u pe rvisingnu rs e or m e d ic
al re c
ord s d ire c
tor, will not be as s igne d c
orporate
d u ties s u c
has tim e ke e ping, payrollorhu m an re s ou rc
e s ac
tivities .
9. ID O C to d e ve lopand im ple m e nt aplan whic
had d re s s e s fac
ility-s pe c
ificc
ritic
als taffing
ne e d s by nu m be r and ke y pos itions and aproc
e s s to e xpe d ite hiringof s taff whe n the
c
ritic
alle ve lhas be e n bre ac
he d .
IDOC Office of Health Services Staffing Recommendations

1. Im m e d iate ly s e e k approval, inte rview and fillthe Infe c
tion C ontrolC oord inatorpos ition.
2. E s tablishand fillthe pos i
tion foratraine d Q u ality Im prove m e nt C oord inatorwho willbe
re s pons ible ford ire c
tingthe s ys te m wide C Q I program .
3. E s tablish, id e ntify and fillthe pos i
tions for thre e re gionalphys ic
ians traine d and board
c
are who willre port to the A ge nc
y M e d ic
alD ire c
torand pe rform at a
m inim u m pe e r re view c
linic
al e valu ations , d e ath re views , re view and e valu ate
d iffic
u lt/c
om plic
ate d m e d ic
al c
as e s , re view and as s ist with m e d ic
ally c
om plic
ate d
trans fe rs , atte nd C Q I m e e tings and one d ay awe e k, within the irre gion, e valu ate patients .
R e s ou rc
e s forthe s e pos itions c
ou ld be take n from m onies alloc
ate d to the m e d ic
alve nd or
forre gionalphys ic
ians .
Overview of Major Services

Clinic Space and Sanitation
C linics pac
e , s anitation and e qu ipm e nt are proble m aticat e ac
hfac
ility withthe e xc
e ption ofH ill
C orre c
tionalC e nte r. T he iss u e s range d from no d e s ignate d s pac
e id e ntified to c
ond u c
t s ic
kc
all
in hou s ingu nits , to d e s ignate d s pac
e be inginad e qu ate ly e qu ippe d to d e s ignate d s pac
e provid ing
no privac
y orc
onfid e ntiality d u ringthe he althc
are e nc
ou nte r.
Fore xam ple , at State s ville , on the firs t floorofc
e llhou s e s B , C , D , E , Fand the X -hou s e , ac
e ll
has be e n c
onve rte d for u s e as as ic
kc
allare a. T he s e are as in c
e llhou s e s B , E and Fhave no
e xam ination table s . A d d itionally, e ac
hofthe are as re tains the ope n-front c
e lld oor with bars
whic
hprovide s for no privac
y or c
onfid e ntiality d u ringas ic
kc
alle nc
ou nte r. A s are s u lt, the s e
id e ntified are as c
annot be c
ons ide re d as appropriate c
linic
als pac
e . In ad d ition, the s e are as are
ve ry noisy.
A t the N orthe rn R e c
e ption C e nte r, c
e ll hou s e s we re originally d e s igne d to inc
lu d e aroom for
he alth c
are e nc
ou nte rs on the firs t floor of e ac
h hou s ingu nit. T he s e are as have allbe e n take n
10
ove r by s e c
u rity s taff and are be ing u s e d as the c
e ll hou s e s e c
u rity offic
e r
s offic
e . If
appropriate ly e qu ippe d , the s e are as wou ld m e e t the c
rite riaas be ingappropriate c
linics pac
e.
A t D ixon, the e xam ination room s u s e d by the phys ic
ian and ad vanc
e le ve lprac
titione rs in the
he alth c
are u nit are appropriate ly e qu ippe d and provide the re qu ire d le ve l of privac
y and
c
onfid e ntiality. T he are as d e s ignate d for nu rs ing c
all, howe ve r, are ju s t the oppos ite . T he
d e s ignate d room s are inappropriate ly e qu ippe d as the y have no e xam ination table s , and provid e
for no privac
y d u ringan e xam ination d u e to large wind ows whic
h we re re qu ire d for s e c
u rity
re as ons . A d d itionally, one id e ntified s ic
kc
allare ais in ahallway at ad e s k. O bviou s ly, this are a
is inappropriate for u s e as it has no e qu ipm e nt, and the re is a total lac
k of privac
y and
c
onfid e ntiality.
O fpartic
u lar c
onc
e rn was that s u pe rvisingnu rs ings taffwas totally u naware ofthe d e fic
ienc
ies
pe rtainingto the s e are as . T his s u gge s ts s ignific
antly u nd e rd e ve lope d profe s s ionalove rs ight.
In the hou s ingu nit u s e d forad m inistrative and d isc
iplinary s e gre gation, whic
his the X -hou s e , a
room was d e s igne d to be u s e d for s ic
kc
alle nc
ou nte rs ;howe ve r, the are ais not be ingu s e d . If
appropriate ly e qu ippe d , this are awou ld m e e t the c
rite riaas an appropriate c
linics pac
e.
A t P ontiac
,c
e llhou s e c
linics pac
e has be e n id e ntified and is be ingu s e d as s u c
h bu t is totally
inappropriate . T he are as are old c
om m u nals tyle s howe rroom s whic
hhave not be e n re d e s igne d
in any way. T he are as have no e qu ipm e nt and provide no privac
y or c
onfid e ntiality. M e age r
ac
c
om m od ations we re m ad e , in that old phys ical the rapy table s are be ingu s e d rathe r than
e xam ination table s . T he phys ic
althe rapy table s are old withc
rac
ke d and torn c
ove rings and , by
d e s ign, d o not allow forthe he ad ofthe table to be e le vate d .
T he Logan he althc
are u nit e xam ination room s are appropriate ly e qu ippe d and provid e s u ffic
ient
patient privac
y and c
onfid e ntiality d u rings ic
kc
alle nc
ou nte rs . In the X -hou s e , whe re re c
e ption,
s e gre gation and m axim u m -s e c
u rity inm ate s are hou s e d , two room s have be e n d e s ignate d fors ic
k
c
all. O ne ofthe room s is u s e d by an ad vanc
e d le ve lprac
titione r and the othe r by nu rs ings taff.
T he hou s ingu nit was ve ry noisy, to the point that anu rs e pe rform ingthe re c
e ption nu rs e s c
re e n
was obs e rve d havings ignific
ant d iffic
u lty talkingwithapatient who was s ittingle s s than thre e
fe e t away. A d d itionally, the nu rs ings ic
kc
allroom was ve ry s m alland c
ram pe d .
A t Illinois R ive r, the he althc
are u nit e xam ination room s are appropriate ly e qu ippe d and provid e
s u ffic
ient privac
y and c
onfid e ntiality. In the X -hou s e , whic
h hou s e s ad m inistrative and
d isc
iplinary s e gre gation inm ate s , no c
linics pac
e has be e n id e ntified . T he c
onc
e rn is that nu rs ing
s taffwillnot pe rform ane e d e d e xam ination be c
au s e the y willnot bothe rs e c
u rity s taffto re m ove
the inm ate /patient from his c
e ll and e s c
ort him to the he alth c
are u nit whe re an appropriate
e xam ination c
an be c
ond u c
te d .
T he re we re no iss u e s in this are aat H illC orre c
tionalC e nte r. H e althc
are u nit e xam ination room s
are appropriate ly e qu ippe d and provide s u ffic
ient privac
y and c
onfid e ntiality. A d d itionally, a
room in the X -hou s e , whic
h hou s e s s e gre gation inm ate s , is u s e d for s ic
kc
all, and the room is
appropriate ly e qu ippe d and provide d s u ffic
ient privac
y and c
onfid e ntiality.
11
T he M e nard he alth c
are u nit e xam ination room s we re appropriate ly e qu ippe d and provide d
s u ffic
ient privac
y and c
onfid e ntiality. Spac
e has be e n e s tablishe d in e ac
hc
e ll hou s e , Sou th
(u ppe rand lowe r), N orth, N orth2, E as t and W e s t, to c
ond u c
t e ithe rnu rs e orphys ic
ian s ic
kc
all.
T he ide ntified are as we re form e r inm ate c
e lls and ne ve r d e s igne d as a c
linic
al e nvironm e nt.
C u rre ntly, the are as provid e little to no privac
y, and all of the are as are not appropriate ly
e qu ippe d . R e novations have be gu n in the E as t C e ll H ou s e to provide for an appropriate ly
e qu ippe d , c
le an, private c
linic
als e tting. R e novation ofallthe are as in e ac
hhou s ingu nit s hou ld
be m ad e apriority.
In N orth 2, an appropriate ly e qu ippe d room is be ingu s e d for s ic
k c
all;howe ve r, the are a
provide s for no privac
y d u ringan e xam ination. A d d itionally, the room u s e d by the c
orre c
tional
m e d ic
alte c
hnic
ian, who c
ond u c
ts s ic
kc
all, d oe s not have an e xam ination table .
In re gard to s anitation, the re we re iss u e s ac
ros s the s ys te m . In m any ofthe fac
ilities , e xam ination
table s and s tools , infirm ary m attre s s e s and s tre tc
he rs we re obs e rve d to have c
rac
ke d or torn
im pe rviou s ou te rc
oatings whic
hd o not allow forthe ite m s to be prope rly c
le ane d and s anitize d
be twe e n patients . In e ac
hins tanc
e , the re had be e n no work ord e rs u bm itte d to re pairthe ite m and
no re qu e s ts s u bm itte d for pu rc
has e of ne w ite m s . A d d itionally, m any of the fac
ilities are not
u s ingapape rbarrier, whic
hc
an be c
hange d be twe e n patients , on the e xam ination table s , norwas
the ir e vid e nc
e of wipingd own the e xam ination table with a s anitizingliqu id /spray be twe e n
patients whe n pape r is not u s e d . A t M e nard , the re was no s ink for hand was hingin the Sou thLowe rc
e llhou s e s ic
kc
allare a.
Recommendations:
1. A lls ic
kc
allm u s t take plac
e in ad e s ignate d are athat allows s ic
kc
allto be c
ond u c
te d in
an appropriate s pac
e that is prope rly e qu ippe d and provide s for patient privac
y and
c
onfid e ntiality.
2. E qu ipm e nt, m attre s s e s , e tc
., whic
h have an im pe rviou s ou te r c
oatingm u s t be re gu larly
ins pe c
te d for inte grity and re paire d or re plac
e d if it c
annot be appropriate ly c
le ane d and
s u ffic
iently s anitize d .
3. A pape r barrier whic
hc
an be re plac
e d be twe e n patients s hou ld be u s e d on all
e xam ination table s .
4. H and was hingors anitizingm u s t be provide d in alltre atm e nt are as .
Reception
W e visite d thre e re c
e ption c
e nte rs and c
le arly, form ale s , the bu lk ofthe ne wly ad m itte d inm ate s
e nte r throu gh the N orthe rn R e c
e ption C e nte r. Ju s t as c
u s tod y, by u s ing d atabas e s and
finge rprints m ake s s u re that it id e ntifies who the patients are in ord e r to ins u re that the y are
appropriate ly hou s e d , s o too the m e d ic
al re c
e ption proc
e s s is d e s igne d to id e ntify ac
u te and
c
hronicm e d ic
alproble m s alongwithac
u te and c
hronicm e ntalhe althproble m s , as we llas any
pote ntial c
om m u nic
able d ise as e s and any othe r s pe c
ial ne e d s . T he pu rpos e of d oing a
c
om pre he ns ive m e d ic
alintake is not ju s t to ide ntify the ne e d s bu t to ins u re that thos e ne e d s are
appropriate ly ad d re s s e d . W e fou nd proble m s withboththe ide ntific
ation and the follow throu gh
in te rm s of m e e tingthe patients ne e d s . W he n e ithe r type of proble m oc
c
u rs , this c
re ate s an
avoidable liability for the patient. B y avoid able liability we m e an both pote ntial harm for the
12
patients as we llas pote ntialle galliability for the s tate . A t N R C the re are s u bs tantiald e lays in
m e d ic
ally proc
e s s ingpatients throu gh the re c
e ption proc
e s s . In s om e ins tanc
e s , the s e d e lays
e xte nd form ore than am onth.
A t the tim e ofou rvisit to N R C , we fou nd be twe e n 200-300m e d ic
alre c
ord s ofpatients who had
re c
e ive d anu rs e s c
re e n and who we re awaitingaphys ic
ale xam by an ad vanc
e d le ve lc
linic
ian.
M any ofthe s e patients had be e n the re m ore than two we e ks . M e d ic
alre c
ord s are d isorganize d
and inhibit the provision ofad e qu ate s e rvic
e s . U nd e rthe pre s u m ption that patients willm ove ou t
within two we e ks , d oc
u m e nts are loos e ly d roppe d into the m e d ic
alre c
ord rathe rthan be ingfile d
and ye t N R C is re s pons ible for patients , partic
u larly at the m e d iu m -s e c
u rity u nit, who m ay s tay
for ye ars . T he s e m e d ic
al re c
ord s are d ys fu nc
tional. T he d e gre e to whic
h m e d ic
al re c
ord s are
d isorganize d im pe d e s the ability ofc
linic
ians to u tilize and ide ntify available c
linic
alinform ation
and the re fore im pe d e s the ir ability or re d u c
e s the probability of the ir re s pons e be ingc
linic
ally
appropriate . W e als o fou nd that the c
u rre nt form s be ingu s e d d o not e lic
it qu e s tions re gard ing
c
u rre nt s ym ptom s as is s tand ard in m os t s ys te m s . Finally, the re is no proc
e s s to ins u re that T B
te st re s u lts , blood te s t re s u lts and any othe r te s ts are inte grate d alongwith the history and
phys ic
alinto aproble m list and plan for e ac
h proble m . T his the re fore inhibits the intras ys te m
trans fe r s e rvic
e . A d d itional s taffing m ay be ne c
e s s ary with re gard to c
linic
ians involve d in
re c
e ption at N R C as we llas the m e d ic
alre c
ord s proc
e s s at N R C . E xam ple s of failu re s of the
re c
e ption proc
e s s at N R C inc
lu d e apatient e nte ringwithahistory ofapos itive T B s kin te s t that
was ne ve r followe d u p. A nothe r e xam ple is a patient whos e intake laboratory s c
re e ning
d e m ons trate d s ignific
ant live r abnorm alities bu t this appare ntly we nt u nnotic
e d . A nothe r
e xam ple is apatient whos e blood pre s s u re was s ignific
antly e le vate d withahistory ofhighblood
pre s s u re and the re was no follow-u p. T his is partic
u larly proble m aticbe c
au s e hype rte ns ion te nd s
to be an as ym ptom aticd ise as e . A lthou gh it m ay not be c
au s ings ym ptom s , while the blood
pre s s u re is e le vate d we know that the re c
an be d am age to the he art and the c
ard iovas c
u lar
s ys te m . D e s pite a patient with H IV havingabnorm al laboratory s tu d ies s u gge s tive of poorly
c
ontrolle d H IV , the re has be e n no follow-u p. A nothe r e xam ple is apatient with ahistory of
he patitis C who was to be as s e s s e d and s c
he d u le d in two we e ks bu t no follow-u pe ve roc
c
u rre d .
A nothe rpatient ne wly arrive d withas e izu re d isord e rand c
he s t wallte nd e rne s s was s u ppos e d to
be followe d u pin one m onthbu t that als o d id not happe n.
W ithre gard to M e nard , apatient e nte re d withe le vate d lipid s tu d ies bu t this was ne ve rid e ntified
norwas it ad d re s s e d . A nothe re xam ple is apatient withas thm aand C O P D who was plac
e d in the
infirm ary bu t d id not have ac
om pre he ns ive e xam forhis lu ngproble m fortwo we e ks . A t Logan,
whe n we re viewe d ne w intake re c
ord s , am ajority ofthos e re c
ord s d id c
ontain proble m s . M os t of
the proble m s re late d to d e lays in follow-u pbu t the re was als o apatient withas thm awho d id not
re c
e ive an ad e qu ate e valu ation. T he s e d e fic
ienc
ies not only s u gge s t bre akd owns whic
hc
re ate
s ignific
ant liability for the patients , bu t als o an abs e nc
e of an organize d s ys te m of s e lfm onitoringin ord e rto ins u re that what ne e d s to be d one is in fac
t d one .
W e wou ld s u gge s t as s igningape rs on as re c
e ption proc
ess c
oord inator who wou ld m aintain the
e qu ivale nt of an E xc
e l-type s pre ad s he e t with the le ft hand c
olu m n c
ontainingthe nam e and
id e ntifiers of the patient and the n s u bs e qu e nt c
olu m ns inc
lu d ingd ate of arrival, d ate of nu rs e
sc
re e n, d ate of labd raw, d ate ofT B s kin te s t, d ate of phys ic
ale xam and finally d ate of initial
proble m list and plan whic
his d e ve lope d from re viewingallofthe d ata. T his E xc
e ls pre ad s he e t
13
s hou ld have d atainpu t d aily and patients wou ld be d ire c

te d to go to thos e are as for whic
hthe y
have not ye t had the re qu ire d s e rvic
e within the re qu ire d tim e fram e . Finally, ac
linic
ian wou ld
re view the re c
ord s ofpatients withid e ntified proble m s and ins u re that appropriate follow u phas
be e n initiate d . A c
olu m n c
ou ld be c
re ate d afte r the c
olu m n on initialproble m list and plan in
whic
h he althy patients wou ld be d iffe re ntiate d from patients with id e ntified proble m s and
the re fore only the latter grou p wou ld have the ir re c
ord s re viewe d by the re s pons ible c
linic
ian.
O n a we e kly bas is, the d ata wou ld be re porte d and on a m onthly bas is the d ata wou ld be
s u m m arize d in are port to the qu ality im prove m e nt c
om m itte e .
Recommendations:
1. A s ys te m that ins u re s re le vant e le c
tronicd ataarrive s withthe patients from C ook C ou nty
Jail.
2. Su ffic
ient nu rs ingand c
linic
ian s taff to c
om ple te the re c
e ption e valu ation within one
we e k.
3. A proc
e s s that ins u re s ac
linic
ian re views allintake d ata, inc
lu d inglaboratory te s ts , T B
sc
re e ning, history and phys ic
al, e tc
., and d e ve lops a proble m list and plan for e ac
h
proble m .
4. Form s to ide ntify ac
u te s ym ptom s .
5. A re qu ire m e nt that c
linic
ians , d u ringthe history, e laborate on allpos itive s from the nu rs e
sc
re e n.
6. A s ys te m of plac
ing on hold patients in the m id s t of appointm e nts or inc
om ple te
tre atm e nt.
7. A policy that re qu ire s the m e d ic
alre c
ord to be we llorganize d and the s taffto ins u re this
is ac
c
om plishe d .
8. A qu ality im prove m e nt proc
e s s that m onitors c
om ple te ne s s , tim e line s s and profe s s ional
pe rform anc
e and is able to inte rve ne in ord e rto im ple m e nt im prove m e nts .
9. A M e d ic
alD ire c
tortraine d in prim ary c
are .
10. A H e althC are U nit A d m inistratorpos ition d e d ic
ate d to N R C and appropriate s u pe rvisory
re s ou rc
es.
11. A we ll-traine d Q u ality Im prove m e nt C oord inator at e ac
h re c
e ption c
e nte r and e ac
h
fac
ility d e d ic
ate d to ins u ring the tim e line s s , c
om ple te ne s s and profe s s ional
appropriate ne s s ofthe c
linic
ald e c
isions .
Intrasystem Transfer
T he polic
y on intras ys te m trans fe rs c
ons ists of c
u s tod y provid ingfor m e d ic
al s taff a list of
nam e s ofpe ople who are to be trans fe rre d , u s u ally within 24hou rs . It is m e d ic
al
s re s pons ibility
to re view the re c
ord s and id e ntify proble m s , c
u rre nt m e d ic
ations , alle rgies , s c
he d u le d
appointm e nts and any othe r s ignific
ant he alth iss u e s . T he s e ite m s are liste d on the intras ys te m
trans fe rs u m m ary whic
hgoe s withthe inm ate whe n he is trans fe rre d . W he n the inm ate arrive s at
the pe rm ane nt fac
ility, he arrive s withhis re c
ord , the trans fe rs u m m ary and any m e d ic
ations . T he
polic
y re qu ire s that are c
e ivingnu rs e re views the ke y e le m e nts ofthe trans fe rs u m m ary, s u c
has
c
hronicproble m s , m e d ic
ations , alle rgies , appointm e nts and anythinge ls e ofs ignific
anc
e withthe
patient, obs e rve s the patient and pe rform s vitals igns . T he pu rpos e ofthis proc
e s s , like m e d ic
al
re c
e ption, is to ins u re that c
ontinu ity ofc
are is fac
ilitate d . W e looke d at the intras ys te m trans fe r
proc
e s s in s e ve ral fac
ilities . A lthou gh we fou nd proble m s in alm os t e ve ry fac
ility, the rate of
14
proble m s was lowe s t at the H illC orre c

tionalC e nte r and was highe s t at D ixon. A t D ixon, the
proc
e s s was s o broke n that d e s pite the fac
t that D ixon has as pe c
ialm e d ic
alm iss ion, inc
lu d ing
ge riatricpatients , whe n patients arrive d the y we re not im m e d iate ly s e e n by a nu rs e with the
re c
ord who re views the trans fe r s u m m ary with the patient and pe rform s vital s igns . In fac
t,
virtu ally e ve ry intras ys te m trans fe rre c
ord we re viewe d was s ignific
antly flawe d and in m any of
the m the proc
e s s was not initiate d u ntiltwo or m ore we e ks afte r the patient had arrive d . T his
gu arante e s d e lays in c
are . E xam ple s ofd e laye d intras ys te m trans fe r re views inc
lu d e a37-ye arold withas thm awho arrive d at D ixon on 2/4/2014, bu t the patient was not s e e n and the trans fe r
s u m m ary re viewe d and c
om ple te d u ntile ight d ays late r, and e ve n the n the re was no re fe rralto
the as thm ac
linic
. A nothe re xam ple is a27-ye ar-old withm u ltiple s c
le ros is whos e he althtrans fe r
s u m m ary was c
om ple te d approxim ate ly thre e we e ks afte r he arrive d , bu t d e s pite the trans fe r
proc
e s s be ingc
om ple te d , the re was no re fe rralto ac
hronicc
are c
linicforhis m u ltiple s c
le ros is.
T he re is a 30-ye ar-old who arrive d with thyroid proble m s and lipid proble m s . H is trans fe r
s u m m ary was c
om ple te d 11 d ays afte r he arrive d and again the re is a failu re to re fe r to the
c
hronicc
are program for his hypothyroid ism . Finally, in one of the D ixon d e ath re views , a
patient was id e ntified who was d iagnos e d with e arly pros tate c
anc
e r at C ook C ou nty Jail. O ne
m onthafte rre c
e ption, he was trans fe rre d to D ixon, whe re he was hou s e d in the infirm ary d u e to
his oxyge n ne e d s re late d to c
hronicobs tru c
tive pu lm onary d ise as e . T his patient was ne ve r
re fe rre d to an u rologist e ve n thou ghthat re fe rrals hou ld have be e n m ad e on e ntry to D ixon. T his
patient d ied in Fe bru ary 2013 from c
om plic
ations of m any of his d ise as e s . T his type ofs e ve re
bre akd own ins u re s d e lays in ac
c
e s s to s e rvic
e s and d isru pts c
ontinu ity of c
are . In s e ve ral
fac
ilities , althou ghthe proc
e s s was m ore c
om pliant withthe polic
y than at D ixon, approxim ate ly
one -third of the re c
ord s we re viewe d we re s ignific
antly proble m atic
. T his again s pe aks to an
abs e nc
e ofs e lf-m onitoringand s e lf-c
orre c
ting.
Recommendations:
1. C u s tod y m u s t propos e alist oftrans fe rringinm ate s to m e d ic
alat le as t 24 hou rs prior to
trans fe r.
2. Inm ate s with s c
he d u le d offs ite s e rvic
e s s hou ld be plac
e d on m e d ic
al hold u ntil the
s e rvic
e has be e n provide d .
3. A nu rs ings u pe rvisors hou ld re gu larly re view as am ple oftrans fe r s u m m aries ofpatients
abou t to be trans fe rre d to ins u re the c
om ple te ne s s ofthe d ata.
4. O ffic
e ofH e althSe rvic
e s s hou ld provid e agu id e as to how to e ffic
iently re view are c
ord
to ide ntify im portant e le m e nts to be inc
lu d e d in the s u m m ary.
5. W he n patients arrive , the y m u s t be brou ght to the m e d ic
al u nit and a nu rs e m u s t be
re s pons ible forfac
ilitatingc
ontinu ity ofre qu ire d s e rvic
es.
6. A t le as t qu arte rly this s e rvic
e m u s t be re viewe d by the Q I program .
Medical Records
T he qu ality of the m e d ic
alre c
ord s was poor at m os t of the fac
ilities we visite d . P roble m lists
we re fre qu e ntly not u pd ate d and ofte n c
lu tte re d withre d u nd ant and irre le vant inform ation, s u c
h
as e ac
htim e the patient was s e e n in c
hronicc
are c
linic
. In m any ins tanc
e s , im portant inform ation
was m iss ingfrom the he althre c
ord s , s u c
has the M A R s from the las t s e ve ralm onths . T he re we re
blanks on the M A R s at virtu ally e ve ry fac
ility. A t thos e ins titu tions with a re c
e ption c
e nte r
fu nc
tion, d rop filingis u s e d , m e aningloos e pape rs are d roppe d into afold e r. T his re s u lts in
15
d isorganize d re c
ord s that are d iffic
u lt and tim e c
ons u m ingto gle an inform ation from . T he wors t
in this re gard was N R C , whe re nothingwas properly file d no m atterhow longthe patients we re
hou s e d the re . A t Logan we e nc
ou nte re d large pile s ofloos e filings tac
ke d in the ins id e c
ove rof
m os t c
harts . Se ve ralof the fac
ilities we visite d d id not file s ic
kc
alls lips in c
harts and s om e
rou tine ly d isc
ard e d the m . T he e xte nt to whic
h m e d ic
alre c
ord m ainte nanc
e is d isorganize d and
d ys fu nc
tionalc
ontribu te s to the like lihood ofale s s we llinform e d c
linician who willthe re fore be
le s s able to m ake the appropriate c
linic
ald e c
isions . W he n le s s appropriate c
linic
ald e c
isions are
m ad e , appropriate c
are m ay e ithe r be s ignific
antly d e laye d or in fac
t not oc
c
u r at all. M e d ic
al
re c
ord m ainte nanc
e s hou ld fac
ilitate inform e d c
are and appropriate c
linic
ald e c
ision m aking.
A s writingnote s by hand is c
u m be rs om e and tim e c
ons u m ing, m os t note s c
ontaine d ve ry little
inform ation withre s pe c
t to s ym ptom histories (nu rs e s te nd e d to d o be tte rthan provid e rs in this
re gard ), phys ic
ale xam s or m e d ic
ald e c
ision m aking. In ne arly allfac
ilities , the hand writingof
one or m ore provide rs was s o ille gible that it re nd e re d the note s allbu t u s e le s s to anyone othe r
than the au thor.
It is ou ru nd e rs tand ingthat the s tate has pu rc
has e d an e le c
troniche althre c
ord s ys te m whic
hwill
be im ple m e nte d in the ne ar fu tu re . T his s hou ld s olve s om e ofthe s e iss u e s , s u c
h as ille gibility,
bu t it is le s s c
le arthat othe rs , s u c
has the proble m lists and thorou ghne s s ofd oc
u m e ntation, will
be im prove d by im ple m e ntation of an e le c
troniche alth re c
ord . W e we re told that e xisting
re c
ord s willnot be s c
anne d into the e le c
tronics ys te m . T his willre s u lt in re d u nd anc
y ofre c
ord s
and thu s gre ate r d isarray and m ore ine ffic
ienc
y than c
u rre ntly e xists . In the e nd , the qu ality of
the e le c
troniche alth re c
ord will d e te rm ine if the trans ition re s u lts in an im prove m e nt in
e ffic
ienc
y, qu ality and patient s afe ty, or m e re ly a re d u nd anc
y in re c
ord ke e ping with the
atte nd ant proble m s that s u c
has ys te m c
re ate s .
Recommendations:
1. P roble m lists s hou ld be ke pt u pto d ate .
2. O nly provid e rs s hou ld have privile ge s to m ake e ntries on the proble m list.
3. T he s ys te m ofd ropfilings hou ld be aband one d .
4. M e d ic
alre c
ord s s taff s hou ld trac
k re c
e ipt ofallou ts ide re ports and e ns u re that the y are
file d tim e ly in the he althre c
ord .
5. C harts s hou ld be thinne d re gu larly and M A R s file d tim e ly.
6. C ons id e ration s hou ld be give n to s c
anning s pe c
ificim portant re c
ord s into the ne w
e le c
tronics ys te m ifpos s ible .
Nursing Sick Call

N u rs ings ic
kc
allrange s from proble m aticto s ignific
antly broke n throu ghou t the s ys te m , in that
one or m ore of the e le m e nts re qu ire d of aprofe s s ionals ic
kc
alle nc
ou nte r are m iss ing. T he s e
e le m e nts are :
1. Sic
kc
allre qu e s t s lips are available to inm ate s .
2. C om ple te d re qu e s ts are plac
e d d ire c
tly by the inm ate into aloc
ke d box orhand e d d ire c
tly
to ahe althc
are s taffm e m be r.
3. C om ple te d re qu e s ts are c
olle c
te d by ahe althc
are s taffm e m be r.
16
4.
5.
6.
7.
T he re is id e ntified c
linics pac
e.
T he c
linics pac
e is appropriate ly e qu ippe d .
T he c
linics pac
e provide s patient privac
y and c
onfid e ntiality.
Sic
k c
all inc
lu d ingpape r triagingis c
ond u c
te d by a lic
e ns e d re giste re d nu rs e whos e
ed u c
ation, lic
e ns u re and s c
ope ofprac
tic
e pe rm it ind e pe nd e nt as s e s s m e nt.
8. Sic
kc
all is c
ond u c
te d pu rs u ant to the polic
ies and proc
e d u re s of the ID O C O ffic
e of
H e alth Se rvic
e s in re gard to the u s e of approve d tre atm e nt protoc
ols at e ac
h e nc
ou nte r,
re qu ire d d oc
u m e ntation, re qu ire d u s e of ove r-the -c
ou nte r m e d ic
ation d os age s only and
re fe rrals /follow-u pas ne e d e d .
9. A s ic
kc
alls ys te m m u s t ins u re c
onfid e ntiality from re qu e s t to tre atm e nt.
10. A s ic
k c
all s ys te m whic
h ad d re s s e s all of a patient
s c
om plaints or, at a m inim u m ,
prioritize s the c
om plaints .
11. A s ic
kc
alllogortrac
kings ys te m has be e n d e ve lope d and m aintaine d .
O ne or m ore ofthe s e e le m e nts was m iss ingat e ac
h fac
ility ins pe c
te d . T he re we re e xam ple s at
e ac
hfac
ility ofe ithe r no ide ntified c
linics pac
e to poorly e qu ippe d c
linics pac
e that provide s no
patient privac
y or c
onfid e ntiality, to e s tablishe d polic
y and proc
e d u re not be ingfollowe d , to
tre atm e nt protoc
ols not be ingu s e d or followe d and to non-m e d ic
al s taff hand lingc
onfid e ntial
s ic
kc
allre qu e s ts . A t e ve ry fac
ility, as ic
kc
allproc
e s s has be e n e s tablishe d whic
h allows for
non-re giste re d nu rs e s to c
ond u c
t s ic
k c
all and , at m any of the fac
ilities , partic
u larly in the
s e gre gation u nit, le gitim ate s ic
kc
allis not be ingc
ond u c
te d bu t in its plac
e afac
e -to-fac
e triage
whe re the R N , LP N or C orre c
tion M e d ic
alT e c
hnic
ian talks to the patient throu ghas olid s te e l
d oor oc
c
u rs . W ithou t an appropriate phys ic
alas s e s s m e nt, this fac
e -to-fac
e triage re s u lts in the
form u lation and im ple m e ntation of a plan of tre atm e nt bas e d s ole ly on the inm ate /patient
s
c
om m e nts withno c
olle c
tion ofobje c
tive d atas u c
has vitals igns oraphys ic
ale xam ination. T his
d oe s not m e e t the d e finition of aprofe s s ional as s e s s m e nt re qu iringan ad e qu ate history, vital
s igns , an appropriate phys ic
alas s e s s m e nt and the s ynthe s is ofthe d atainto anu rs ingd iagnos is
and the d e ve lopm e nt of an appropriate plan. W ithou t s u c
h aprofe s s ionalas s e s s m e nt the re is a
s ignific
antly re d u c
e d like lihood of an appropriate d iagnos is and an appropriate plan and this
inc
re as e s the pote ntialfor harm to the patients . D u ringthe s ic
kc
allproc
e s s the re giste re d nu rs e
orin the ins tanc
e s u gge s te d by the State , an LP N , is e xpe c
te d to d o aphys ic
alas s e s s m e nt, that is
e xam ine the throat or e ye s or e ars , etc
. Su pe rvising, i.e ., re viewingthe d oc
u m e ntation bas e d on
su c
has s e s s m e nts be ingpe rform e d d oe s not allow one to c
onfirm that the as s e s s m e nt was in fac
t
ac
c
u rate and appropriate . T he re is no e ffic
ient way for R N s to s u pe rvise this proc
e s s and give n
the inad e qu ate trainingthat LP N s have in phys ic
alas s e s s m e nt, it is only appropriate that the
re s pons ibility forc
ond u c
tings ic
kc
allbe lim ite d to re giste re d nu rs e s . T he N C C H C ac
c
re d its 25be d jails as we llas large prisons and althou gh the re has not be e n agre e m e nt on d e finingwhat
le ve lof s taffings hou ld be c
re d e ntiale d for s ic
kc
all bas e d on the s ize of the ins titu tion, the re
have be e n s u c
h d isc
u s s ions . T he C om m iss ion
s pos ition is that the s c
ope of prac
tic
e allowe d
within a give n s tate is d e te rm ine d by the s tate nu rs ing board and this is ac
c
e ptable to the
N ationalC om m iss ion on C orre c
tionalH e althC are . A re view ofthe Illinois N u rs e P rac
tic
e A c
t
d esc
ribe s ind e pe nd e nt as s e s s m e nts , whic
he s s e ntially is what as ic
kc
allas s e s s m e nt is, are only
s anc
tione d for pe rform anc
e by re giste re d nu rs e s . Lic
e ns e d prac
tic
al nu rs e s m ay as s ist in or
partic
ipate in an as s e s s m e nt bu t m ay not ind e pe nd e ntly pe rform s ic
kc
allas we fou nd in s om e
prisons .
17
W hile it is ID O C polic
y that e ac
h m onth the ins titu tional M e d ic
al D ire c
tor re views the
d oc
u m e ntation oftwo s ic
kc
alle nc
ou nte rs pe rprovid e r, i.e ., R N , LP N orC M T forc
om ple te ne s s ,
this is are tros pe c
tive pape rre view to d ete rm ine that the provide rans we re d allthe qu e s tions and
c
he c
ke d allthe boxe s on the pre -printe d tre atm e nt protoc
olform . T he re is no way, howe ve r, for
the phys ic
ian re viewe r to d ete rm ine if the provid e r ac
c
u rate ly inte rpre te d and d oc
u m e nte d
phys ic
alfind ings in ord e rto d ete rm ine an appropriate as s e s s m e nt and tre atm e nt.
A t e ac
hofthe fac
ilities ins pe c
te d , whe n anon-re giste re d nu rs e c
ond u c
te d s ic
kc
all, the re was no
im m e d iate re view by a re giste re d nu rs e or phys ic
ian to ins u re the provide r c
ond u c
te d an
appropriate phys ic
alas s e s s m e nt and ac
c
u rate ly inte rpre te d phys ic
alfind ings.
O fpartic
u larc
onc
e rn, s pe c
ific
ally at State ville and P ontiac
, is the fre qu e nt arbitrary c
anc
e llingof
s ic
kc
alle nc
ou nte rs by s e c
u rity s taff. Su c
hprac
tic
e s re pre s e nt s ignific
ant im pe d im e nts to ac
c
ess
to c
are and re s u lt in d e lays in tre atm e nt.
O fnotable c
onc
e rn at D ixon is the prac
tic
e ofm e d ic
als taffonly pe rm ittingapatient to voic
e one
c
onc
e rn at an e nc
ou nte r d e s pite m u ltiple c
onc
e rns liste d on the s ic
kc
allre qu e s t. Sinc
e inm ate s
are c
harge d ac
o-pay form e d ic
als e rvic
e s , inm ate s inte rviewe d at D ixon we re ofthe opinion that
be ingpe rm itte d to have only one he althc
are c
om plaint ad d re s s e d at an e nc
ou nte rwas am one y
m akings c
he m e forthe State .
A t s om e fac
ilities , m os t notably N R C and D ixon, it was d iffic
u lt to im pos s ible to e valu ate s ic
k
c
allbe c
au s e aSic
k C allLoghas not be e n d e ve lope d orm aintaine d . In fac
t, d u ringthe fou rd ays
at N R C , as ic
kc
alllist c
ou ld not be pre s e nte d e ve n thou ghre qu e s te d m u ltiple tim e s .
H illC orre c
tionalC e nte r has d e ve lope d as ic
kc
alls ys te m withthe above nu m be re d e le m e nts in
plac
e . O nly rare ly d oe s anon-re giste re d nu rs ings taff m e m be r re view/triage s ic
kc
allre qu e s ts
and c
ond u c
t s ic
kc
all. T his ge ne rally happe ns whe n s ic
kc
allflows ove r to the 3-11 s hift, and a
Lic
e ns e d P rac
tic
alN u rs e wou ld c
om ple te any re m ainings ic
kc
allfrom the d ay s hift.
Recommendations:
1. E ac
hfac
ility is to d e ve lopand im ple m e nt aplan to ins u re :
a) Sic
kc
allis c
ond u c
te d in ad e fine d c
linic
als pac
e that is appropriate ly e qu ippe d and
provide s patient privac
y and c
onfid e ntiality.
b) Sic
kc
allre qu e s ts are c
onfid e ntialand to be viewe d only by m e d ic
als taff.
c
) T he re view/triage ofs ic
kc
allre qu e s ts and c
ond u c
tingofs ic
kc
allis pe rform e d by a
lic
e ns e d re giste re d nu rs e .
d ) Le gitim ate s ic
kc
alle nc
ou nte rs to inc
lu d e c
olle c
tingahistory, m e as u re m e nt of vital
s igns , visu alobs e rvations and ahand s -onphys ic
alas s e s s m e nt.
e ) T he re m u s t not be arbitrary re s tric
tions on the nu m be rofs ym ptom s to be ad d re s s e d at
an e nc
ou nte r.
f) FollowingO ffic
e ofH e althSe rvic
e s e s tablishe d polic
y and proc
e d u re.
g) C om ple te d oc
u m e ntation.
h) Im ple m e ntation and m ainte nanc
e ofas ic
kc
alllog.
2. A d m inistration m u s t ins u re he alth c
are ac
tivities s u c
h as s ic
k c
all are not rou tine ly
c
anc
e lle d , as this re s u lts in an u nac
c
e ptable d e lay in he althas s e s s m e nt.
18
Chronic Disease Management

T he ID O C c
hronicc
are program s u ffe rs from d e fic
ienc
ies in its polic
ies and gu id e line s , as we ll
as we akne s s e s with re s pe c
t to the variable qu ality of the ind ivid u al prac
titione rs , and lac
k of
c
linic
alove rs ight bothloc
ally and c
e ntrally.
W ithre gard to polic
y iss u e s , the m os t im portant and ove rarc
hingproble m is the c
ookie c
u tte r
approac
h to c
hronicd ise as e m anage m e nt, in that polic
y d ic
tate s that allpatients are s om e what
arbitrarily s e e n only thre e tim e s aye arre gard le s s ofhow we llorhow poorly the ird ise as e c
ontrol
m ay be . P atients s hou ld be s e e n in ac
c
ord anc
e withthe d e gre e ofc
ontrolofthe ird ise as e s , with
poorly c
ontrolle d patients s e e n with gre ate r fre qu e nc
y, and we ll c
ontrolle d patients s e e n le s s
fre qu e ntly. T he c
onc
e pt of d ise as e c
ontrolin this c
onte xt is d e rive d from the N C C H C c
hronic
d ise as e gu id e line s whic
hwe re in fac
t d e ve lope d by the le ad e rofthe inve s tigative te am . H e was
tas ke d with d e ve lopingthe s e gu id e line s for the pu rpos e of fac
ilitatinggood d ise as e c
ontrolas
e xpe d itiou s ly as pos s ible in ord e r to d e c
re as e the risk of avoidable m orbid ity and the re by
im provingpatient ou tc
om e s . H owe ve r, whe n this c
onc
e pt is im ple m e nte d by the d e s ignate d
m onthapproac
h, it d oe s not e nc
ou rage c
linic
ians to work as aggre s s ive ly as pos s ible withthe ir
patients to ac
hieve good d ise as e c
ontrol and the re by e xpos e s patients to longe r pe riod s of
inc
re as e d risk ofharm .
A qu arte rly visit only m ake s s e ns e (and is s afe )if patients d ise as e s are in good c
ontrol. Ifnot,
the n patients are e xpos e d to the c
u m u lative organ d am age c
au s e d by inad e qu ate ly c
ontrolle d
c
hronicd ise as e . T his d e gre e of e xpos u re is what le ad s to avoidable m orbid ity and m ortality.
W hile it is c
u rre ntly pos s ible for provid e rs to arrange for m ore fre qu e nt follow u p, this is le ft
e ntire ly to the d isc
re tion ofthe ind ivid u alprac
titione rand by no m e ans oc
c
u rs on are gu larbas is.
A t e ve ry fac
ility we visite d , we e nc
ou nte re d c
as e s of patients with poorly c
ontrolle d c
hronic
d ise as e goingm onths withou t any ac
tive m anage m e nt ofthe ird ise as e proc
e s s , e ve n ifthe y we re
s e e n in c
linicforothe r, le s s im portant iss u e s .
B y as s ignings pe c
ificm onths ofthe ye ar for the m anage m e nt ofe ac
hd ise as e , the c
hronicc
are
program (pe rhaps inad ve rte ntly) c
re ate s a fragm e nte d and ine ffic
ient s ys te m of c
are whe re in
patients with m u ltiple d ise as e s are s e e n for only one d ise as e pe r c
ale nd ar m onth. W e
e nc
ou nte re d m u ltiple e xam ple s whe re in patients who we re s e e n in c
hronicc
linicor at s ic
kc
all
forone illne s s had e vid e nc
e ofpoorc
ontrolofanothe rd ise as e , bu t the poorly c
ontrolle d d ise as e
was not ad d re s s e d , pre s u m ably be c
au s e it was not the d e s ignate d m onth(orvisit type )to ad d re s s
it. T he re we re notable e xc
e ptions to this, s u c
has M e nard and H illC orre c
tionalC e nte rs , whe re
the c
hronicc
linicnu rs e s have d e ve lope d c
om pre he ns ive form s d e s igne d to ad d re s s allc
hronic
d ise as e s in one visit. A t othe r fac
ilities , s u c
h as State ville and P ontiac
, all d ise as e s are als o
ad d re s s e d at as ingle visit bu t the provide rfills ou t m u ltiple c
hronicc
are form s , aproc
e s s which
is re d u nd ant, ine ffic
ient and tim e c
ons u m ing. W e re c
om m e nd that the State ad opt a s ys te m
s im ilar to M e nard or H ill whic
h re pre s e nts a m ore c
om pre he ns ive and u nified approac
h to
c
hronicd ise as e m anage m e nt.
O the r im portant polic
y iss u e s re late to the m anage m e nt ofs pe c
ificd ise as e s , m os t notably H IV
and C O P D . W ith re s pe c
t to the H IV polic
y, the re is no ID O C T re atm e nt Gu id e line for H IV ;
the re is only the W e xford H e alth H IV /A ID S Infe c
tion C ontrolP olic
y, whic
h d oe s not re qu ire
that fac
ility provid e rs follow the H IV patients who are not followe d by the fac
ility provid e rs for
19
the ir H IV d ise as e . In e ve ry fac

ility we visite d , the s e patients we re m anage d s ole ly by the ID
s pe c
ialist via te le m e d ic
ine for the ir H IV infe c
tion. W hile the H IV c
ons u ltants are e xc
e lle nt
s pe c
ialists , the y are not prim ary c
are provide rs . T he s e patients have ac
hronicd ise as e in the s am e
s e ns e that d iabe te s , hype rte ns ion orc
oronary arte ry d ise as e is ac
hronicd ise as e . In othe rword s ,
havingad ise as e that re qu ire s the inte rve ntion of as pe c
ialist d oe s not obviate the ne e d for a
prim ary c
are provid e r. W hile we wou ld not e xpe c
t the ave rage prim ary c
are provid e r to be
profic
ient at pre s c
ribingH IV tre atm e nt, it is e xpe c
te d that allprovid e rs at le as t be fam iliarwith
the bas icprinc
iple s of tre atm e nt, the im portanc
e of m e d ic
ation c
om plianc
e and the m os t
c
om m on s id e e ffe c
ts offre qu e ntly u s e d m e d ic
ations . T he H IV viru s re ad ily d e ve lops re s istanc
e
m u tations whe n m e d ic
ations are not take n e xac
tly as pre s c
ribe d . O nc
e this happe ns , thos e
m e d ic
ations be c
om e u s e le s s in the tre atm e nt ofthe patient
s d ise as e .
Give n the lim ite d nu m be r of m e d ic
ations available to tre at this life -thre ate ninginfe c
tion, it is
e xtre m e ly im portant that patients u nd e rs tand the im portanc
e of m e d ic
ation ad he re nc
e and are
followe d c
los e ly to e ns u re the y are takingthe m e d ic
ations c
orre c
tly and tole ratingthe m . So for
e xam ple , whe n the H IV s pe c
ialist s tarts or c
hange s am e d ic
ation, it is ge ne rally re c
om m e nd e d
that the patient have a follow-u p appointm e nt within a fe w we e ks to inqu ire abou t ad ve rs e
e ffe c
ts and ad he re nc
e . W e e nc
ou nte re d nu m e rou s e xam ple s ofpatients goingford ays , we e ks or
m onths withou t the ir m e d ic
ations , e ithe r be c
au s e of re fu s als or othe r s ys te m iss u e s , and the s e
tre atm e nt inte rru ptions we nt u nnotic
e d by the loc
al provid e rs be c
au s e the y are not ac
tive ly
following this d ise as e proc
e s s . For e xam ple , patient [REDACTED] we nt withou t his H IV
m e d ic
ations for an e ntire m onth, bu t this we nt u nre c
ognize d u ntil his follow-u p te le m e d ic
ine
visit m onths late r. P atient [REDACTED] we nt at le as t two d ays withou t any ofhis m e d ic
ations d u e
to ac
e llm ove . P atient [REDACTED], who was on d e e p s alvage the rapy for his H IV d ise as e , had
his m e d ic
ation ord e re d , and the re fore ad m iniste re d , inc
orre c
tly for m onths be fore it was
c
orre c
te d at the ne xt te le m e d ic
ine c
linicvisit d e s pite the fac
t that he was followe d in the c
hronic
c
are program for his othe r d ise as e s . In ou ropinion, the provide rs lac
k offam iliarity withthe s e
patients and withH IV d ise as e its e lfplac
e s the patients at u nne c
e s s ary risk ofad ve rs e ou tc
om e .
W e re c
om m e nd that the s e patients are ac
tive ly followe d by fac
ility provide rs in the c
hronicc
are
program .
In m os t c
orre c
tionals ys te m s , e ve n whe n the H IV patients c
are is ove rs e e n by an H IV s pe c
ialist,
the prim ary c
are c
linic
ian within the c
hronicc
are program m onitors blood te s t re s u lts as we llas
the ir patients s u bje c
tive and obje c
tive d ata. W he n iss u e s are id e ntified by the prim ary c
are
c
linic
ian (e .g., rising viral load s ), the patient is re fe rre d to the H IV s pe c
ialist or the H IV
s pe c
ialist is c
ontac
te d . In ge ne ral, d e c
isions to initiate orc
hange tre atm e nt are m ad e by the H IV
s pe c
ialist.
W ith re gard to the m anage m e nt of pu lm onary d ise as e s , the tre atm e nt gu ide line is s e riou s ly
d e fic
ient, in that it only ad d re s s e s the tre atm e nt of as thm a and not of othe r obs tru c
tive lu ng
d ise as e s s u c
h as C O P D and c
hronicbronc
hitis, whic
h are c
om m on and im portant c
au s e s of
m orbid ity and m ortality in the U .S. and the tre atm e nt ofwhic
h d iffe rs in im portant ways from
the tre atm e nt ofas thm a. It was the re fore not s u rprisingto find that in the m ajority ofc
as e s we
re viewe d , patients withlu ngd ise as e we re tre ate d as ifthe y had as thm ae ve n ifthe y c
le arly had
C O P D , s arc
oidos is ors om e othe rpu lm onary d ise as e . T he N C C H C tre atm e nt gu ide line s , while a
re as onable s tartingpoint, are ne arly 15 ye ars old and d o not s pe c
ific
ally ad d re s s C O P D or
20
pu lm onary d ise as e s othe r than as thm a. A s the inc

arc
e rate d popu lation has age d , C O P D has
be c
om e am u c
hm ore prom ine nt d ise as e e ntity in this grou pand ne e d s to be tre ate d ac
c
ord ingto
c
u rre nt nationally ac
c
e pte d c
linic
algu id e line s . T he c
u rre nt ID O C as thm agu id e line appe ars to be
bas e d partly on the N ationalH e art, Lu ngand B lood Ins titu te (N H LB I)E xpe rt P ane lR e port 3
(E P R 3). Fore xam ple , the s e c
tion on as s e s s ings ym ptom s e ve rity is c
ons iste nt withthe N H LB I
re c
om m e nd ations , bu t the as s e s s m e nt of c
ontrol is not. T he N H LB I gu id e line s als o take into
ac
c
ou nt ad d itional d ata, s u c
h as s ym ptom inte rfe re nc
e with norm al ac
tivity and pe ak flow
m onitoringwhe n as s e s s ingd e gre e of c
ontrol. W e re c
om m e nd that the d e partm e nt ad opt this
s trate gy. W e als o re c
om m e nd the d e partm e nt m im icthe N H LB I in its c
ontrolte rm inology of
we ll,not we ll,and ve ry poorlyc
ontrolle d rathe rthan good , fair, poorc
ontrolin ord e rto
he ighte n aware ne s s of the ne e d to m od ify the rapy for all c
ate gories that are le s s than we ll
c
ontrolle d .
W ith re gard to the c
are of patients with d iabe te s , we note d anu m be r of proble m s at variou s
fac
ilities . Fore xam ple , we obs e rve d that at s om e fac
ilities it appe are d to be c
om m on prac
tic
e to
rou tine ly s witc
h patients from ins u lin re gim e ns that m im icthe bod y
s own ins u lin prod u c
tion
(s o-c
alle d inte ns ive ins u lin the rapy) to s im ple r bu t non-phys iologicre gim e ns (known as
c
onve ntional ins u lin the rapy) re gard le s s of the type of d iabe te s the patient had . T his ofte n
oc
c
u rre d u pon arrival and in the abs e nc
e of a visit with the c
linic
ian. T his prac
tic
e is
inappropriate for s e ve ralre as ons . Firs t, type s 1 and 2 d iabe te s are qu ite d iffe re nt d ise as e s , with
the form e rc
harac
te rize d by ins u lin d e fic
ienc
y and the latterby ins u lin re s istanc
e. A s su c
h, the y
re qu ire d iffe re nt and ind ivid u alize d approac
he s to ins u lin the rapy. C onve ntionalins u lin the rapy
is u nlike ly to ac
hieve targe t blood s u gar le ve ls in patients with type 1 d iabe te s , who as
m e ntione d are ins u lin d e fic
ient and for whom phys iologicins u lin re plac
e m e nt is typic
ally
re c
om m e nd e d and is the s tand ard ofc
are in the c
om m u nity. T ype 2 d iabe tic
s on the othe r hand
re tain varyingd e gre e s ofins u lin prod u c
tion u ntilthe late s tage s ofthe d ise as e and c
an ofte n be
m anage d with s im ple r ins u lin re gim e ns , at le as t u ntil the ir own ins u lin prod u c
tion e ve ntu ally
fails and the y too re qu ire m ore inte ns ive re gim e ns .
In e ithe r c
as e , be c
au s e patients d iffe r in the ir e atinghabits , ac
tivity le ve ls and s e ns itivity to
ins u lin (e s pe c
ially in the c
as e oftype 2d iabe tic
s ), ind ivid u alize d approac
he s to the m anage m e nt
ofthe ir ins u lin re gim e ns is re qu ire d . T his e ntails m onitoringpatients blood s u garre ad ings ove r
tim e as we llas d isc
u s s ions with patients re gard ings ym ptom s of low or high blood s u gar and
e valu ation ofthe ir c
om plianc
e withd iet, e xe rc
ise and m e d ic
ations . A rbitrarily c
hangingins u lin
re gim e ns be fore takinginto ac
c
ou nt allof the s e variable s c
an re s u lt in d e te rioration of d ise as e
c
ontroland d oe s nothingto fos te r are lations hip bas e d on tru st and c
om m u nic
ation, whic
h is
vitally im portant to e nhanc
ec
om plianc
e.
A sec
ond iss u e we e nc
ou nte re d is that m any ofthe fac
ilities are s tillu s ingthe ou td ate d ID D M
(ins u lin d e pe nd e nt d iabe te s m e llitu s ) vs . N ID D M (non-ins u lin d e pe nd e nt d iabe te s m e llitu s )
te rm inology to c
ate gorize d iabe ticpatients . T his te rm inology was aband one d in the c
om m u nity
m any ye ars ago be c
au s e it is im pre c
ise and m isle ad ing. T he proble m withlabe lingd iabe tic
s this
way is that it d oe s not d iffe re ntiate be twe e n type 1and type 2d iabe te s , whic
hare phys iologic
ally
d istinc
t e ntities as pre viou s ly m e ntione d . A lltype 1d iabe tic
s are ins u lin d e pe nd e nt by d e finition.
H owe ve r, m any type 2d iabe tic
s re qu ire ins u lin to ke e pthe ird ise as e u nd e rc
ontrol, bu t in m any
21
c
as e s it m ay be appropriate to als o u s e oralage nts in this popu lation. W e re c
om m e nd that all
patients be c
ate gorize d as e ithe rT ype 1orT ype 2d iabe tic
s as is the c
om m u nity s tand ard .
R e gard le s s ofthe type ofd iabe te s , it is im portant that alld iabe tic
s have re liable m e altim e s whic
h
c
los e ly c
orre late with m e d ic
ation ad m inistration in ord e r to m aintain blood s u gar le ve ls within
s afe range s . H owe ve r, we note d that at s om e fac
ilities , m e altim e s c
an be highly variable and
the re fore s o too c
an be the tim ingbe twe e n ins u lin ad m inistration and the s tart ofthe m e al. T he
e xtre m e e xam ple in this re gard is State ville , whe re bre akfas t is s e rve d d u ringwhat m os t pe ople
wou ld c
ons id e r the m id d le of the night, be twe e n 1:30 a.m . to 3:30 a.m . A t M e nard , m orning
ins u lin is ad m iniste re d be twe e n 2:30 a.m . and 3:30 a.m . and bre akfas t is s e rve d be twe e n 4:30
a.m . and 5:00 a.m . C ons id e ringthat the ons e t of ac
tion of re gu lar ins u lin is abou t 30 m inu te s ,
this pre s e nts a s ignific
ant risk of low blood s u gar for the s e patients whic
h m ay c
au s e brain
d am age , c
om aor d e ath. W he n patients have as u s taine d e le vation of blood s u gar, the re s u lt is
pote ntiald am age to the blood ve s s e ls in the he art, the brain, the kid ne ys and the e ye s . T he re fore ,
it is e xtre m e ly im portant forpatients to re c
e ive appropriate re gim e ns that c
ontroland re gu late the
le ve lofs u garin the blood .
A lthou gh the re are pas s ingc
om m e nts in the O ffe nd e r P hys ic
al E xam ination A D (04.03.101)
re gard ingthe fre qu e nc
y of he alth s c
re e ningfor wom e n, the s e gu id e line s are inad e qu ate . For
e xam ple , this A D s tate s that A paps m e ars hallnot be re qu ire d forfe m ale s ove rage 65provide d
the y have re c
e ive d ad e qu ate prior s c
re e ning bu t d oe s not s tate what ad e qu ate prior
sc
re e ningc
ons ists of. Like wise , that s am e polic
y goe s on to state that am am m ogram s hallbe
re pe ate d e ve ry othe r ye ar for fe m ale s of age s 50 throu gh 75, bu t d oe s not stipu late any
s itu ations in whic
h e arlier or m ore fre qu e nt s c
re e ningwou ld be ind ic
ate d . W e note d m u ltiple
c
as e s ofwom e n who d id not re c
e ive ne c
e s s ary s c
re e ningte s ts . A t Logan, we note d that patients
typic
ally ge t aP aps m e aron intake , bu t the re we re fre qu e ntly d e lays withs u bs e qu e nt follow-u p
c
are and rou tine P aps the re afte r, e s pe c
ially for H IV infe c
te d wom e n who re qu ire m ore fre qu e nt
sc
re e ningthan u ninfe c
te d wom e n d u e to the ir inc
re as e d risk for invas ive c
e rvic
alc
anc
e r. W e
re c
om m e nd the c
re ation ofac
hronicd ise as e c
linicd e vote d to wom e n
s he alththat inc
lu d e s m ore
s pe c
ificgu id anc
e on the s e iss u e s .
W ith re gard to the m anage m e nt of pu lm onary d ise as e s , the tre atm e nt gu ide line is s e riou s ly
d e fic
ient, in that it only ad d re s s e s the tre atm e nt of as thm a and not of othe r obs tru c
tive lu ng
d ise as e s s u c
h as C O P D and c
hronicbronc
hitis, whic
h are c
om m on and im portant c
au s e s of
m orbid ity and m ortality in the U S and the tre atm e nt ofwhic
hd iffe rs in im portant ways from the
tre atm e nt of as thm a. It was the re fore not s u rprisingto find that in the m ajority of c
as e s we
re viewe d , patients withlu ngd ise as e we re tre ate d as ifthe y had as thm ae ve n ifthe y c
le arly had
C O P D , s arc
oidos is ors om e othe rpu lm onary d ise as e . T he c
u rre nt as thm agu id e line appe ars to be
bas e d partly on the N ationalH e art, Lu ngand B lood Ins titu te (N H LB I)E xpe rt P ane lR e port 3
(E P R 3). Fore xam ple , the s e c
tion on as s e s s ings ym ptom s e ve rity is c
ons iste nt withthe N H LB I
re c
om m e nd ations , bu t the as s e s s m e nt of c
ontrol is not. T he N H LB I gu id e line s als o take into
ac
c
ou nt ad d itional d ata, s u c
h as s ym ptom inte rfe re nc
e with norm al ac
tivity and pe ak flow
m onitoringwhe n as s e s s ingd e gre e of c
ontrol. W e re c
om m e nd that the d e partm e nt ad opt this
s trate gy. W e als o re c
ontrolte rm inology of
we ll,not we ll,and ve ry poorlyc
ontrolin ord e rto
he ighte n aware ne s s of the ne e d to m od ify the rapy for all c
ate gories that are le s s than we ll
c
ontrolle d .
22
In the c
ou rs e of ou r re views we note d m u ltiple ins tanc
e s in whic
h patients e xpe rienc
ed
m e d ic
ation d isc
ontinu ity for a variety of re as ons , ye t this we nt u nre c
ognize d and the re fore
u nad d re s s e d by the tre atingc
linic
ians . P art of the proble m s e e m s to be d ys fu nc
tional m e d ic
al
re c
ord ke e ping, whe re by m e d ic
ation ad m inistration re c
ord s (M A R s )we re not file d tim e ly into
the c
harts . In othe rc
as e s , nu rs e s had knowle d ge that patients we re s kippingd os e s ofm e d ic
ations
ye t d id not notify the pre s c
ribe r. P olic
y s hou ld re qu ire that patients who m iss m e d ic
ations for
any re as on (failto re qu e s t are fill, re fu s e , no-s how, e tc
.)are re fe rre d to aprovide rto ad d re s s the
iss u e . T he polic
y s hou ld als o re qu ire that all c
hronicd ise as e patients on nu rs e -ad m iniste re d
m e d ic
ations have ac
opy of the ac
tive M A R plac
e d in the re c
ord whe n the patient is s e e n for
c
hronicd ise as e follow u p.
Sinc
e it is an offic
e r
s re s pons ibility to c
he c
k forand id e ntify c
ontraband and be gin the proc
ess
of s anc
tioning the inm ate , this re s pons ibility e xists als o d u ring m e d ic
ation ad m inistration.
N u rs e s d o not have are s pons ibility profe s s ionally to be s e arc
hingforc
ontraband . Ifthe y id e ntify
it the y are obligate d to re port it, bu t s e arc
hingfor it is not part ofthe ir re s pons ibilities . D u ring
the m e d ic
ation ad m inistration proc
e s s , the y c
an be d oc
u m e ntingthe m e d ic
ation ad m inistration,
c
he c
kingthe re c
ord s to d ete rm ine whe the rthe ne xt patient
s m e d ic
ations are pre s e nt, avariety of
things re late d to the proc
e s s as oppos e d to pe rform ingwhat is atypic
alc
u s tod y fu nc
tion.
Recommendations:
1. P atients s hou ld be s e e n in ac
c
ord anc
e withthe d e gre e of c
ontrolof the ir d ise as e s , with
m ore poorly c
ontrolle d patients s e e n m ore fre qu e ntly and we llc
ontrolle d patients s e e n
le s s fre qu e ntly.
2. C hronicc
are form s and flow s he e ts s hou ld be u pd ate d and be d e s igne d s o that allc
hronic
d ise as e s are ad d re s s e d at e ac
hvisit.
3. H IV patients s hou ld be followe d re gu larly by ID O C provide rs in the c
hronicc
are
program to ad d re s s the ir prim ary c
are ne e d s , m onitor for m e d ic
ation c
om plianc
e , s id e
e ffe c
ts ofthe rapy and ove rallhe alths tatu s .
4. T he A s thm aT re atm e nt Gu ide line s hou ld be re plac
e d withagu ide line on the tre atm e nt of
pu lm onary d ise as e s to inc
lu d e C O P D and c
hronicbronc
hitis as we ll as as thm a. T his
gu ide line s hou ld be m od e le d afte rthe N H LB I re port.
5. T he re s hou ld be ac
hronicc
linicd e vote d to wom e n
s he althto inc
lu d e s pe c
ificgu id e line s
on c
e rvic
aland bre as t c
anc
e rs c
re e ningas we llas othe riss u e s u niqu e to this popu lation.
6. T he T B gu id e line s hou ld be u pd ate d to provide bas icinform ation re gard inginte rfe ron
gam m ate s ting, inc
lu d ingappropriate u s e s ofthis te s t.
7. P olic
y s hou ld re qu ire that patients who m iss m e d ic
ations re pe ate d ly or for as ignific
ant
pe riod oftim e are re fe rre d to aprovid e rto ad d re s s the iss u e .
8. C opies ofthe c
u rre nt M A R s hou ld be available forthe provide r
s re view d u ringc
hronic
c
are c
linic
.
Pharmacy/Medication Administration
A t all fac
ilities , B os we llP harm ac
e u tic
als , loc
ate d in P itts bu rgh, P A , provide s the pre s c
ription
and non-pre s c
ription m e d ic
ations . B os we ll is lic
e ns e d as a W hole s ale D ru g
D istribu tor/P harm ac
y D istribu tor and ac
u rre nt lic
e ns e was available at alls ite s . T he s e rvic
e is
23
fax and fill, m e aningpre s c

riptions faxe d to B os we llby ad e s ignate d tim e e ac
hd ay willarrive
the ne xt d ay. E ac
h fac
ility has d e s ignate d a bac
k-u p pharm ac
y in the c
om m u nity to obtain
u rge ntly ne e d e d m e d ic
ations . E ac
h fac
ility had at le as t one fu ll-tim e pharm ac
y te c
hnic
ian who
was re s pons ible for the d ay-to-d ay ope ration of the m e d ic
ation room inc
lu d ing ord e ring,
re c
e ivingand inve ntorying. B os we llprovid e s ac
ons u ltingpharm ac
ist to c
om e on-s ite m onthly
to as s ist the pharm ac
y te c
hnic
ians , c
he c
k inve ntories and atte nd qu ality im prove m e nt m e e tings.
R and om c
he c
ks ofc
ontrolle d m e d ic
ation, s yringe /ne e d le and m e d ic
altoolpe rpe tu alinve ntories
we re allac
c
u rate and be ingc
ou nte d /ve rified at the appropriate inte rvals . N one of the fac
ilities
re porte d any proble m s /iss u e s withpharm ac
y s e rvic
e s and none we re note d .
R e gard ingm e d ic
ation ad m inistration, the re is ac
onc
e rn at the N R C . H e althc
are s taffad m iniste r
m e d ic
ation d os e -by-d os e at the c
e ll. T he N R C has apolic
y that he althc
are s taffis e s c
orte d at all
tim e s whe n in ac
e llhou s e . O bs e rvation ofm e d ic
ation ad m inistration re ve ale d s ignific
ant d e lays
be c
au s e as e c
u rity s taff m e m be r was not as s igne d and available in e ac
hc
e ll hou s e to provid e
esc
ort. A s e c
u rity s taffm e m be rwas finally provid e d afte rs e ve ralre qu e s ts and as ignific
ant tim e
d e lay. It was obs e rve d that the s e c
u rity e s c
ort provide d no s e rvic
e othe r than walkingwiththe
he alth c
are s taff m e m be r. It is ou r re c
om m e nd ation that s e c
u rity offic
e rs , followingpatient
inge s tion, s hou ld c
he c
k for c
ontraband . W hile we fu lly agre e it is the re s pons ibility of m e d ic
al
s taff to d e live r and ad m iniste r m e d ic
ation, at the point the inm ate re c
e ive s the m e d ic
ation and
e le c
ts to not inge s t it, the u ninge s te d m e d ic
ation is c
ontraband , and offic
e rs s e arc
h/c
he c
k for
c
ontraband , not m e d ic
als taff. M e d ic
als taff d oe s not fu nc
tion as an arm of c
u s tod y. It wou ld
s e e m , s inc
e inm ate s are ac
c
u s tom e d to s e c
u rity s taff rou tine ly pe rform ingc
e ll s e arc
he s for
c
ontraband , inm ate s wou ld be m ore like ly to c
oope rate with offic
e rs in the pe rform anc
e of a
m ou th c
he c
k followingm e d ic
ation ad m inistration. Sinc
e offic
e r as s ignm e nts inc
lu d e e s c
orting
m e d ic
als taffd u ringm e d ic
ation ad m inistration, it wou ld s e e m the proc
e s s wou ld be qu ic
ke rand
m ore e ffic
ient if the offic
e r pe rform e d the m ou th c
he c
k, and the m e d ic
al s taff m e m be r c
ou ld
proc
e e d to d oc
u m e nt the m e d ic
ation ad m inistration and be gin to pre pare the m e d ic
ations forthe
ne xt inm ate .
Recommendations:
1. Followingpatient inge s tion of m e d ic
ation, s e c
u rity s taff s hou ld be re s pons ible to c
he c
k
the m ou thforc
ontraband .
2. A s e c
u rity s taff m e m be r m u s t be as s igne d to ac
c
om pany the nu rs e who pe rform s
m e d ic
Laboratory
Laboratory s e rvic
e s at e ac
h fac
ility are provide d throu gh the U nive rs ity of Illinois-C hic
ago
H os pital(U IC ). E ithe r fu ll-tim e phle botom ists ornu rs ings taffd raw and pre pare s pe c
im e ns for
trans port to U IC . R e s u lts are e le c
tronic
ally trans m itte d bac
k to the fac
ility, ge ne rally within 24
hou rs vias e c
u re fax line loc
ate d in the m e d ic
ald e partm e nt. U IC re ports allre portable c
as e s both
to the fac
ility and the Illinois D e partm e nt ofP u blicH e alth. T he re is ac
u rre nt C linic
alLaboratory
Im prove m e nt A m e nd m e nt (C LIA ) waive r c
e rtific
ate on file at e ac
h fac
ility. T he re we re no
re ports ofany proble m s withthis s e rvic
e.
Recommendations: N one
24
Unscheduled Onsite and Offsite Services (Urgent/Emergent)

In ord e r to trac
k u ns c
he d u le d s e rvic
e s and whe re ind ic
ate d to im prove pe rform anc
e , it is
e s s e ntial that an u rge nt c
are or te le phone logbe m aintaine d . U nfortu nate ly, s e ve ral fac
ilities ,
inc
lu d ingD ixon, Logan, N R C and M e nard e ithe rd id not m aintain s u c
halogord id not m aintain
it c
ons c
ientiou s ly. T his d e m ons trate s the im pos s ibility of the ir be ingable to s e lf-m onitor and
im prove pe rform anc
e . Su c
halogs hou ld c
ontain field s for patient ide ntifiers , d ate , tim e , whe re
the patient was s e e n, pre s e ntingc
om plaint, d ispos ition and ifthe patient was s e nt offs ite , afield
for re trieve d offs ite s e rvic
e pape rwork as we llas follow-u p visit withprim ary c
are c
linic
ian or
M e d ic
alD ire c
tor. U ns c
e s u s u ally be gin withaphone c
allfrom ahou s ingu nit to
the m e d ic
alu nit, althou ghoc
c
as ionally patients are brou ght ove rwithou t any priorc
all. W hat is
e xpe c
te d is are giste re d nu rs e pe rform s an initial as s e s s m e nt and the n c
ontac
ts an appropriate
c
linic
ian forad isc
u s s ion. W he n the patient is s e nt offs ite , the patient s hou ld be re tu rne d throu gh
the m e d ic
al are a with the pape rwork s o that a nu rs e c
an re view any re c
om m e nd ations and
c
ontac
t aphys ic
ian ifan ord e r is ne e d e d . In ad d ition, the nu rs e c
an pe rform abriefas s e s s m e nt,
inc
lu d ingvitals igns , in ord e rto ins u re patient s tability. Som e prisons au tom atic
ally plac
e the s e
patients in the infirm ary to be s e e n the followingd ay by aphys ic
ian. If this d oe s not happe n,
the re m u s t be afollow-u pvisit withaprim ary c
are c
linic
ian within afe w d ays . In re viewingthis
s e rvic
e , we fou nd bre akd owns bothby nu rs e s and c
linic
ians in re lations hipto ide ntifyingpatient
ins tability and the re fore arrangingfor the patient to be s e nt offs ite . In ad d ition, we als o fou nd
bre akd owns in te rm s of patients not be ingbrou ght bac
k to the m e d ic
alu nit to anu rs e and we
als o fou nd m os t c
om m only that patients we re re tu rningwithpatient ins tru c
tion pape rwork rathe r
than an e m e rge nc
y room re port or whe n hos pitalize d , ad isc
harge s u m m ary. H os pitals have to
u nd e rs tand that c
orre c
tions patients are retu rningto ad oc
tor and the re fore patient ins tru c
tions
are not u s e fu l. R athe r, an e m e rge nc
y room re port or ad isc
harge s u m m ary c
an be u tilize d by a
c
linic
ian to u nd e rs tand what was d one , what was c
onc
lu d e d and what was re c
om m e nd e d . T he s e
bre akd owns inhibit the provision of appropriate c
are . In ad d ition, we id e ntified s om e patients
who we re not appropriate ly followe d u pby aprim ary c
are c
linic
ian.
In ord e r to ins u re ou ts ide hos pitals c
ons iste ntly provide e m e rge nc
y room re ports whe n the
patient is d isc
harge d , the agre e m e nt withthe hos pitals hou ld be e xplic
it in that the s e rvic
e which
is c
om pe ns ate d by the age nc
y inc
lu d e s boththe ac
tu als e rvic
e and the re port from the e m e rge ncy
room or, with ahos pitalization, ad isc
harge s u m m ary. T hat s trate gy has worke d e ffe c
tive ly in
m any ju risd ic
tions .
Failure to Identify Serious Instability-From Mortality Reviews
T his patient was a56-ye ar-old m an who d ied ofprostate c
anc
e r on 3/21/14. H e was s e e n by an
u rologist in Janu ary 2014and be c
au s e ofs e ve re bac
k pain he was s e nt to the hos pitalon 2/3/14.
H owe ve r, while hou s e d in the infirm ary on 1/30/14, followinghis pros tate biops y, he be gan
d e ve lopingfe ve rs and fe e lingill. B e ginningon 2/2/14, he d e ve lope d te m pe ratu re s ofu pto 104
as we llas an e le vate d pu ls e rate of132. T he nu rs e s appropriate ly notified the phys ician, who d id
not c
om e to as s e s s him u ntil2/3/14 in the e ve ning. H e was u ltim ate ly d iagnos e d and tre ate d for
s e ps is afte r be ings e nt ou t at 11:15 p.m . T his patient c
om plainingof fe ve rs and tac
hyc
ard ia
s hou ld have be e n s e nt ou t im m e d iate ly.
25
From D ixon. T his is a 64-ye ar-old m an with c

hronicobs tru c
tive pu lm onary d ise as e , atrial
fibrillation, hype rte ns ion and pros tate c
anc
e r. H e d ied on 2/28/2013 from tu be rc
u los is,
pne u m oniaand m e ningitis. O n 1/24/13, he was ad m itte d to the hos pitalforprogre s s ive s hortne s s
of bre ath and c
onfu s ion. H e re tu rne d to D ixon on 1/27/13. B e ginning on 2/1, he be c
am e
inc
re as ingly s hort of bre ath, le thargic
, we ak, c
onfu s e d and had inte rm itte nt fe ve rs . O n 2/5, the
patient
s te m pe ratu re was 102. T he phys ic
ian d id not d oc
u m e nt ahistory or phys ic
al e xam .
D e s pite the fac
t that the patient had no e vid e nc
e ofinflu e nz a, the phys ic
ian ord e re d T am iflu . O n
2/6, in re s pons e to apos itive u rine c
u ltu re , the phys ic
ian ord e re d IV antibiotic
s . O n 2/7, the
infirm ary phys ic
ian be gan d oc
u m e ntingthat the patient had an e xtre m e ly poor prognos is. O n
2/11, he d oc
u m e nte d the patient was pos s ibly s e ptic
. O n 2/12, he finally s e nt the patient to the
loc
alhos pital, whe re he was ad m itte d to the IC U forre s piratory failu re . T his patient s hou ld have
be e n s e nt ou t m u c
h e arlier and the d oc
u m e ntation d oe s not d e m ons trate s u ffic
ient c
onc
e rn for
this patient
s he althand s afe ty.
T his is a62-ye ar-old m an who e nte re d ID O C in 2008and d ied on 11/16/13ofGI ble e d ingfrom
ru ptu re d e s ophage al varic
e s d u e to c
irrhos is. T his patient, on 11/13/13, pre s e nte d with s e ve re
le thargy, d izz ine s s , d ys pne aand m e le naX 2d ays . H e was tac
hyc
ard ic
, withahe art rate of104.
H is blood pre s s u re was norm aland he had gros s ly pos itive s tools forblood on e xam . T he d oc
tor
ord ere d labs and plac
e d him in the infirm ary at 1:10p.m . A t 1:30, the ad m ittingnu rs e d e s c
ribe d
him as pale and pas ty. H e had a s m all blac
k s tool c
ons iste nt with ac
u te blood los s . H e
c
om plaine d ofm ild abd om inaland c
he s t pain. H is blood pre s s u re was 112/70and his he art rate
was 100. H is he m oglobin was 10.2 gram s and it had d roppe d from 13.3 gram s fou r m onths
e arlier. A t 8:00 p.m ., a s tat blood c
ou nt was d rawn and the re s u lt at 9:15 was 7.6 gram s ,
s u gge s tive ofs e ve re ble e d inginte rnally. A t 9:45p.m ., the nu rs e c
alle d the d oc
torand he ord e re d
IV flu id s . O n 11/14at 3:25a.m ., his blood pre s s u re was 100/60and his pu ls e 104. A t 9:20a.m .,
the d oc
tor s aw the patient, who c
om plaine d of we akne s s , d izz ine s s and ongoingblood in his
s tools . H e finally s e nt the patient to the hos pitalwhe re he d ied two d ays late r. W he n you id e ntify
apatient who has ac
u te ongoingblood los s , to not s e nd him ou t is inc
om pre he ns ible .
An Inadequate Response Possibly Related to Medical or Custody Staffing
T his is apatient from D ixon who is a48-ye ar-old withas e izu re d isord e r. O n 1/1/14, anu rs e was
c
alle d to the hou s ingu nit foraC od e 3. In the re c
ord the re is no d e s c
ription ofthe e ve nt, bu t the
patient was brou ght to the c
linicand u ltim ate ly wante d to re tu rn to the hou s ingu nit. T he only
note in the re c
ord is anote by an LP N whe re the as s e s s m e nt re ad s , P ost s e izu re . T he patient
was re tu rne d to the hou s ingu nit by the LP N with no c
ontac
t withan ad vanc
e d le ve lc
linic
ian.
T he re was an inad e qu ate history and phys ic
alas s e s s m e nt and s inc
e only an LP N s aw the patient
the re we re s ignific
ant liabilities e nge nd e re d by this re s pons e . T he Illinois State N u rs e P rac
tic
e
A c
tc
le arly s tate s , O nly are giste re d nu rs e m ay pe rform an ind e pe nd e nt as s e s s m e nt.
T he ne xt e xam ple is apatient from Logan who is a35-ye ar-old with as e izu re d isord e r. O n
12/30/13at abou t 11:00p.m ., the c
e llhou s e c
ontac
te d the m e d ic
alu nit to re s pond to this patient,
who was havings e izu re s . W he n the nu rs e arrive d , the s e izu re s had c
e as e d and s he d oc
u m e nte d
that s he obs e rve d no s e izu re s bu t le ft the patient in the hou s ingu nit withou t any ad e qu ate
as s e s s m e nt. O ne d ay late r at 11:40 p.m ., the patient was fou nd in the hou s ingu nit havinga
s e izu re , with blood arou nd he r m ou th and blood d rippingfrom alac
e ration in the bac
k of he r
he ad . She was brou ght to the he alth c
are u nit and s e nt to the loc
al hos pital. T he re was no
26
m e ntion ofc
ontac
tingthe phys ic
ian. T he patient was re tu rne d from the hos pitalat 4:00 a.m . on
1/1/14. T he re are no re c
ord s from the loc
alhos pital. T he phys ic
ian d id c
om e in on 1/1 and s aw
the patient and ord e re d blood le ve ls ofhe ranti-s e izu re m e d ic
ations . H owe ve r, the re has be e n no
follow u ps inc
e by the phys ician. T his patient s hou ld have be e n brou ght to the infirm ary afte rthe
s e izu re on the firs t night for m ore c
are fu l obs e rvation and to be s e e n by a c
linician. T his
c
harac
te rize s as ignific
ant nu rs ingbre akd own.
T he ne xt c
as e is from M e nard and re fle c
ts inad e qu ate nu rs ingas s e s s m e nt followingre tu rn from
the hos pital. T his patient is a61-ye ar-old withos te oporos is who was s e nt ou t on 1/26/14. O n that
d ay at abou t 2:10p.m ., he c
om plaine d ofc
he s t pain fortwo hou rs . H e d e s c
ribe d it as apre s s u re
in his c
he s t and was give n nitroglyc
e rin with s om e re lief. H is blood pre s s u re was e le vate d at
154/90and his pu ls e rate was 116. T he phys ic
ian was c
alle d and the ord e rwas to s e nd him to the
hos pital. T he patient we nt to the hos pitaland re tu rne d one we e k late r, on 2/3and was plac
e d in
the infirm ary for obs e rvation. H e was s e e n late r that d ay by the nu rs e , who d id not as k any
qu e s tions re gard ingc
he s t pain, s hortne s s of bre ath or the inc
isions on his c
he s t. H e was late r
s e e n by anu rs e prac
titione r whos e note ind ic
ate s the patient had re c
e ntly had c
oronary arte ry
bypas s graft s u rge ry bu t ne ithe r the nu rs e prac
titione r nor the nu rs e e lic
ite d any s u bje c
tive
re s pons e s from the patient. T he patient was u ltim ate ly re le as e d to the c
e ll. T he re c
ord , at the tim e
ofou r re view, s tilllac
ke d any d isc
harge s u m m ary or m ore im portantly, the c
athe te rization and
ec
ho re ports , c
ritic
alpiec
e s that m u s t be part ofthe m e d ic
alre c
ord .
T he ne xt c
as e is als o from M e nard and d e m ons trate s inappropriate u s e ofs taff. T his patient is a
57-ye ar-old withhype rte ns ion, he patitis C d ise as e and s u bs tanc
e abu s e iss u e s . H e pre s e nte d on
3/28/14 c
om plainingof lowe r abd om inalpain, ac
hingand bu rning, with five loos e s tools . H e
was s e e n by aC M T (whic
h is inappropriate s inc
e he ne e d e d an as s e s s m e nt). H e s hou ld have
be e n s e e n at am inim u m by are giste re d nu rs e or am id le ve lprovid e r. H e was re fe rre d to the
phys ic
ian the ne xt d ay and whe n s e e n by the phys ic
ian he was im m e d iate ly s e nt ou t to ru le ou t
an ac
u te appe nd ic
itis. In fac
t, he had an ac
u te appe nd e c
tom y and was re tu rne d on 3/31and afte r
an as s e s s m e nt by the M e d ic
al D ire c
tor was re tu rne d to his c
e ll. A lthou gh the re was a
re c
om m e nd ation forhim to be followe d u pat the hos pital, this ne ve rhappe ne d , nor is the re any
note ind ic
atingac
hange from that re c
om m e nd ation.
T he ne xt c
as e is a48-ye ar-old patient withhype rte ns ion and glau c
om a, als o from M e nard . T hos e
two d iagnos e s are the only one s liste d on the proble m list. O n 1/13/14, he c
om plaine d ofc
he s t
pain and was s e nt to the hos pital. T he worku p at the hos pitalwas ne gative for ac
u te c
oronary
arte ry d ise as e and the d iagnos is was re flu x d ise as e . H e re tu rne d from the hos pitaland at the tim e
ofre tu rn his vitals igns we re norm al. T he re is an ord erforan e le c
troc
ard iogram and aphys ician
as s e s s m e nt. T he c
ard iogram was s c
he d u le d for 1/17, bu t the re was anote that s ays it was not
d one be c
au s e of aloc
kd own. T his is aproc
e d u re d one ons ite whic
h s hou ld ne ve r be c
anc
e lle d
be c
au s e ofaloc
kd own. In fac
t, it was not d one u ntile ight d ays late rand at the tim e ofou rvisit,
the re was s tillno c
ard iogram in the c
hart. T his is apatient who had apre viou s history ofbotha
he art attac
k and s u prave ntric
u lar tac
hyc
ard ia (rapid he art rate ), althou gh ne ithe r of the s e
proble m s we re on the proble m list. A n E K G was ord ere d bu t it was d e laye d u nac
c
e ptably and in
fac
t, fou rm onths late rthe re was no re port in the c
hart.
27
A m ajority ofthe re c
ord s we re viewe d c
ontaine d ne ithe r an e m e rge nc
y room re port nor, whe n
patients we re hos pitalize d , a d isc
harge s u m m ary, d e s pite the fac
t that the s e d oc
u m e nts are
c
ru c
ial for appropriate c
ontinu ity of c
are . H os pitals m u s t be e d u c
ate d that c
om pe ns ation for a
s e rvic
e c
annot be provid e d as longas the s e rvic
e whic
hinc
lu d e s the appropriate d oc
u m e ntation
has not be e n provide d .
Recommendations:
1. A llfac
ilities m u s t trac
k u rge nt/e m e rge nt s e rvic
e s throu ghu s ingalogbook m aintaine d by
nu rs ingwhic
h inc
lu d e s patient ide ntifiers , the tim e and d ate , the pre s e ntingc
om plaint,
the loc
ation whe re the patient is s e e n, the d ispos ition and whe n the patient is s e nt ou t, the
re tu rn with the appropriate pape rwork, inc
lu d ing an e m e rge nc
y room re port and
appropriate follow u pby ac
linic
ian.
2. A s s e s s m e nts m u s t be pe rform e d by s taffappropriate ly lic
e ns e d to be re s pons ible forthat
s e rvic
e.
3. Gu ide line s s hou ld be d e ve lope d for nu rs ings taff with re gard to vital s igns re fle c
ting
ins tability that re qu ire c
ontac
tingac
linic
ian.
4. W he n patients are s e nt offs ite , work with hos pitals to ins u re that the e m e rge nc
y room
re port is give n to the offic
e rto retu rn to nu rs ingwiththe patient.
5. P atients re tu rningfrom an e m e rge nc
y trip m u s t be brou ght to a nu rs ingare a for an
as s e s s m e nt and if not plac
e d in the infirm ary, s c
he d u le d for an as s e s s m e nt by an
ad vanc
e d le ve lc
linic
ian.
6. T he O ffic
e s s hou ld provide gu idanc
e with re gard to the type s of
c
linic
al proble m s that re qu ire s e rvic
e s be yond the c
apability of the infirm ary, thu s
s e nd ingpatients to the loc
alhos pital.
7. Ins u re that afte rthe patient retu rns he is s e e n by ac
linic
ian within thre e d ays whe re the re
is d oc
u m e ntation ofad isc
u s s ion ofthe find ings and plan as d e s c
ribe d in the e m e rge ncy
room re port.
8. T he Q I program s hou ld m onitortim e line s s and appropriate ne s s ofprofe s s ionalre s pons e s .
9. A s an as pe c
t ofthe Q I program , re view nu rs ingand c
linic
ian pe rform anc
e to im prove it.
Scheduled Offsite Services (Consultations and Procedures)

A s we u nd e rs tand the proc
e s s for obtainingc
e d u re s , it be gins with the
tim e ly id e ntific
ation of the ne e d for a proc
ed u re or c
ons u ltation, u s u ally for d iagnos tic
as s istanc
e . R e view ofd e athre c
ord s has re ve ale d s om e d e lays in the tim e line s s ofide ntific
ation.
O nc
e the c
linic
ian has d e te rm ine d that the re is a c
linic
al bas is for offs ite s e rvic
e s , the y are
re qu ire d to s u bm it aform whic
hd oc
u m e nts the c
linic
alju s tific
ation forobtainingthe s e rvic
e.
T his form is re viewe d by the s ite M e d ic
alD ire c
tor, who e ithe r c
onc
u rs and pre s e nts it to the
we e kly c
olle gialre view te le phone d isc
u s s ion ors u gge s ts an alte rnate plan ofc
are to the ord e ring
c
linic
ian. W he n an alte rnate plan ofc
are is re c
om m e nd e d , e ithe r by the M e d ic
alD ire c
tororthe
c
olle gialre view te le c
onfe re nc
e , the re m u s t be ad isc
u s s ion be twe e n the ord e ringc
linic
ian and
the patient s o that he /she is on board withthe c
hange in plan. T he te le phonicc
olle gialre view is
pe rform e d we e kly and s o the re s hou ld be no m ore than aone -we e k d e lay d u e to pre s e ntation at
the c
olle gialre view.
28
D u ring the c
olle gial re view, the P itts bu rgh-bas e d phys ic
ian e ithe r approve s the s e rvic
e or
s u gge s ts an alte rnate plan. W e have be e n told by s e ve rals ite s that this rate of approvalvaries
d ram atic
ally bas e d on whic
hP itts bu rgh-bas e d phys ic
ian happe ns to be re c
e ivingthe phone c
all.
Som e approve at a m u c
h highe r rate than othe rs . For D ixon and State ville , d e s pite ve rbal
approval re c
e ive d ove r the te le phone , the re is a s u bs tantial d e lay in P itts bu rgh provid ingthe
au thorization c
od e to the U nive rs ity ofIllinois. T his d e lay c
an e xte nd u pto e ight we e ks orm ore .
T he s c
he d u le rat D ixon and at State ville willc
allthe U nive rs ity ofIllinois s c
he d u le r, who works
c
los e ly withthe m . W e xford c
hange d the proc
e d u re s o that the au thorization is no longe r give n
d ire c
tly to the s c
he d u le rat the s ite ;rathe r, it is give n d ire c
tly to the U ofI s c
he d u le r, bu t as we
ind ic
ate d , this m ay oc
c
u r u p to e ight we e ks late r. T his is c
le arly not ac
c
e ptable . A d d itionally,
the re are s e ve rals pe c
ialties for whic
h U nive rs ity of Illinois m ay not provid e ac
c
e s s for u p to
thre e or m ore m onths . In m any ins tanc
e s , the s e rvic
es c
ou ld be obtaine d m u c
h m ore tim e ly by
u s ingaloc
als e rvic
e rathe rthan the U nive rs ity ofIllinois.
In m os t c
orre c
tionals e ttings, fors c
e s , e m e rge nt c
ons u ltation orproc
e d u re s
are s e nt ou t im m e d iate ly, withou t any u tilization re view u ntilafte r the fac
t. U rge nt s e rvic
e s are
obtaine d in no m ore than 10 bu s ine s s d ays and rou tine s e rvic
e s are ge ne rally obtaine d within 30
c
ale nd ard ays . From what we have s e e n, ge ne rally the s e m e as u re s are obtaine d whe n u s ingloc
al
s e rvic
e s . T he e xtraord inary d e lays te nd to re volve arou nd the u tilization of the U nive rs ity of
Illinois.
O nc
e the patient atte nd s the appointm e nt and re c
e ive s the s e rvic
e , he s hou ld be re tu rne d to an
ons ite nu rs e withany ac
c
om panyingpape rwork, whic
hs hou ld be give n to the nu rs e . T he re are
proc
e d u re s for whic
h one antic
ipate s d ic
tation and trans c
ription and for the s e s e rvic
e s as taff
m e m be rat the ins titu tion m u s t ins u re that the offs ite pape rwork is obtaine d tim e ly. Finally, onc
e
the pape rwork is available ons ite , the re s hou ld be as c
he d u le d visit withthe ord e ringc
linic
ian or
M e d ic
alD ire c
tord u ringwhic
hthe re is ad oc
u m e nte d d isc
u s s ion ofthe find ings and plan.
D u ringou rre view ofre c
ord s , we fou nd bre akd owns in alm os t e ve ry are a, s tartingwithd e lays in
id e ntific
ation of the ne e d for the offs ite s e rvic
e s , d e lays in obtainingan au thorization nu m be r,
d e lays in be ingable to s c
he d u le an appointm e nt tim e ly, d e lays in obtainingoffs ite pape rwork
and d e lays orthe abs e nc
e ofany follow-u pvisit withthe patient. A d d itionally, althou ghs om e of
the fac
ilities we re trac
kingthe s e s te ps fairly c
ons c
ientiou s ly, othe rs we re not, c
re atingm u c
hle s s
d e pe nd able ou tc
om e s . In the be s t ofthe e ight fac
ilities we re viewe d , the re we re proble m s at one
s te p or anothe r in abou t 20% of the re c
ord s . In othe r fac
ilities , s u c
h as D ixon C orre c
tional
C e nte r, the re we re proble m s withalm os t e ve ry re c
ord re viewe d . W hat follows are e xam ple s of
the d iffe ringtype s ofproble m s we id e ntified .
Delays in Perceiving the Need for the Service
Illinois R ive r D e ath R e view. T he patient, [REDACTED], e nte re d ID O C in 2000 and be gan
c
om plainingofc
ons tipation in Janu ary 2011, whe n he we ighe d 195pou nd s . T he patient retu rne d
withac
om plaint ofc
ons tipation in M ay 2011 and ind ic
ate d that he had los t 10 pou nd s . A t that
point, the phys ician d id not d o are c
tale xam . In D e c
e m be rofthe s am e ye arhe ind ic
ate d that he
was los ingwe ight and in fac
t he had los t m ore than 30pou nd s and we ighe d 158. T he d oc
tord id
pe rform are c
tale xam bu t fou nd no m as s e s , althou ghe ve ry s u bs e qu e nt phys ic
ian d id fe e lam as s .
29
She ord e re d labte s ts , whic

hs howe d am ild iron d e fic
ienc
y ane m ia. She the n ord e re d s toolc
ard s
to s e e ifthe re was blood in the s tooland the s e c
am e bac
k pos itive . Finally, he was re fe rre d fora
c
olonos c
opy, whic
h on A pril13, 2012 id e ntified alarge tu m or in the re c
tu m . O nc
e the tu m or
was ide ntified , his c
are was appropriate . H owe ve r, he s u rvive d le s s than aye ar.
H illD e athR e view. P atient [REDACTED] e nte re d ID O C in 1984 and arrive d at H illC orre c
tional
C e nte r in 2009, havings toppe d s m okingtwo ye ars e arlier. H is c
om plaints be gan withle ft ne c
k
and c
he s t pain in Fe bru ary 2012. In M ay 2012, he told anu rs e he was c
ou ghingu pblood , whic
h
he c
onne c
te d to as hou ld e r inju ry. H e was s e e n awe e k late r by the phys ic
ian with m u ltiple
c
om plaints , inc
lu d ingwe ight los s , forwhic
hthe m e d ic
alre c
ord re ve als a30-pou nd we ight los s .
T he phys ician s aw the patient alittle m ore than two we e ks late rand note d ale ft m obile qu arte rs ize d m as s in the le ft s u pe rc
lavic
u lar are a. H e ord e re d iron and ac
he s t x-ray. T he c
he s t x-ray
re ve ale d a foc
al opac
ity in the le ft lowe r lobe with te ntingof the le ft he m id iaphragm . T he
M e d ic
alD ire c
tor s aw the patient in Ju ne and twic
e in Ju ly, and by A u gu s t the patient
s we ight
was d own to 127pou nd s . O n A u gu s t 20, he pre s e nte d c
ou ghingu pblood and the d oc
torord e re d
m ore blood te s ts, whic
hs howe d his ane m iawors e ning. It was not u ntilA u gu s t 31that aC T s c
an
was pe rform e d whic
h s howe d a ve ry large c
arc
inom a whic
h e xte nd s throu gh the s u pe rior
portion ofthe le ft he m ithorax, throu ghthe ape x and involve s the le ft ante riorc
he s t e xte nd ingto
the ante riorplu rals u rfac
e and invad ingthe m e d ias tinu m withtu m ors s u rrou nd ingthe as c
e nd ing
thorac
icaorta, e xte nd ingalongthe aorticarc
h and e nc
irc
lingthe proxim ald e s c
e nd ingthorac
ic
aorta.T his patient d ied oflu ngc
anc
e ron 1/30/13.
Delay in Obtaining Timely Appointment
P ontiac D e ath R e view. T he patient, [REDACTED], was a 42-ye ar-old m an who d ied of
glioblas tom a m u ltiform e on 4/16/13. T he tu m or was firs t d iagnos e d in 2009, prior to his
inc
arc
e ration. H e u nd e rwe nt e xc
ision in M arc
h 2009 and again in Se pte m be r 2010 for
re c
u rre nc
e . H e was ad m itte d to ID O C in Ju ly 2012. H e had are s tagingM R I in O c
tobe r 2012
whic
hs howe d no re c
u rre nc
e and his m ainte nanc
ec
he m othe rapy was d isc
ontinu e d .
A s u bs e qu e nt M R I on 2/1/13 s howe d re c
u rre nc
e of a low grad e e nhanc
ingm as s in his le ft
te m poral lobe and he was re fe rre d for ne u ros u rgic
al c
ons u ltation, bu t this was not s c
he d u le d
u ntil 4/10/13. H owe ve r, on 4/1/13, he was fou nd with alte re d c
ons c
iou s ne s s and s troke -like
s ym ptom s and was take n to St. Jam e s H os pital, whe re C T s howe d s ignific
ant e d e m aarou nd the
m as s and a1c
m m id line s hift. H e was trans fe rre d to U IC , whe re it was d e c
id e d that the risks of
s u rge ry ou twe ighe d the be ne fits . T he fam ily d e c
id e d to withd raw c
are on 4/15/13and the patient
d ied the ne xt d ay.
A two-m onth d e lay in the ne u ros u rge ry c
ons u lt is e xc
e s s ive , give n the natu re of the patient
s
d iagnos is. A lthou gh his long-te rm s u rvival wou ld not like ly have be e n m u c
h be tte r, it s e e m s
like ly that the d e lay allowe d for e nou gh tu m or growth and as s oc
iate d s we llingto pre c
lu d e
fu rthe rtre atm e nt options forthis patient and the re fore s horte ne d his s u rvival.
Delays in Processing the Approval
T his is the c
as e ofapatient from D ixon whos e is a65-ye ar-old m ale withhype rte ns ion, as thm a,
GE R D and apos itive T B s kin te s t. O n 11/20/13, the c
linic
ian ord e re d aC T s c
an ofthe c
he s t to
ru le ou t am as s . T he patient was pre s e nte d at the c
olle gialre view alittle ove r two we e ks late r
30
and on 12/4, an approval was obtaine d . T hre e we e ks late r, the au thorization nu m be r was
provide d . T he re port, the re fore , was d one on 2/12/14, whic
hind ic
ate s s u s pic
iou s forc
anc
e r.A
re qu e s t forapu lm onary c
ons u lt was m ad e and approve d two we e ks be fore ou rarrivaland ye t an
au thorization nu m be rforthis s tillhas not be e n provid e d .
Delays in Following Up an Abnormal Result
T his oc
c
u rre d at H ill C orre c
tional C e nte r from apatient who arrive d at H illon 3/29/13. T his
patient had he patitis C and apriorpos itive s kin te s t. O n 3/21/13, he we nt ou t foran u ltras ou nd of
the abd om e n as re c
om m e nd e d by the he patitis C s pe c
ialist. T he u ltras ou nd s howe d m u ltiple
m as s e s in the live r in D e c
e m be r 2013. T his was re viewe d by the phys ic
ian nine d ays afte r the
s e rvic
e was pe rform e d . O n 3/7/14, the he patitis C s pe c
ialist s aw the patient and re c
om m e nd e d a
C T sc
an. T he C T s c
an was d one on 3/21/14, bu t the re we re no re s u lts in the m e d ic
alre c
ord . T he
patient had als o had an abnorm alu ltras ou nd s e ve ralm onths e arlier whic
hno one had ac
te d on.
W e finally obtaine d the C T re s u lts , whic
hs howe d that the y are like ly be nign tu m ors ofthe live r;
howe ve r, this patient is fortu nate that d e s pite the abs e nc
e offollow-u phis he althis probably not
in je opard y.
Problems with Follow Up
T his is apatient at M e nard who was fou nd to have an e le vate d prostate s c
re e ningte s t and was
re fe rre d to the u rology c
linic
. H e was s e e n the re on A pril8and are c
om m e nd ation was m ad e for
atrans re c
tal-gu ide d biops y. T his was re fe rre d to c
olle gialre view and was approve d . T he patient
was s e e n and hope fu lly inform e d , bu t the re is no note that d oc
u m e nts the patient was aware of
what was planne d . W e c
ou ld not find any s u bs e qu e nt inform ation othe rthan the fac
t that abone
sc
an had be e n ord e re d , bu t the re is no d isc
u s s ion with the patient re gard ingthe bone s c
an.
N othinghas happe ne d re gard ingthe pros tate biops y. T he re was als o ad e lay in re c
e ivingany
re port from the offs ite s e rvic
e.
Finally, at e ve ry fac
ility, the re we re e xam ple s of patients who had re c
e ive d c
ons u ltations or
proc
e d u re s bu t no follow u p with the patient had oc
c
u rre d . T his was qu ite c
om m on at s om e
fac
ilities , inc
lu d ingState ville and D ixon, and le s s c
om m on at othe rs , althou gh it was fou nd
alm os t u nive rs ally at arate ofat le as t be twe e n 20% and 50% ofalls c
es.
Recommendations:
1. T he e ntire proc
e s s , be ginningwiththe re qu e s t fors e rvic
e s , m u s t be trac
ke d in alogbook,
the field s of whic
h wou ld inc
lu d e d ate ord e red , d ate of c
olle gial re view, d ate of
appointm e nt, d ate pape rwork is re tu rne d and d ate offollow-u pvisit withc
linic
ian. T he re
s hou ld als o be afield forapprove d ornot approve d , and whe n not approve d , afollow-u p
visit withthe patient re gard ingthe alte rnate plan ofc
are .
2. P re s e ntation to c
olle gialre view by the M e d ic
alD ire c
torm u s t oc
c
u rwithin one we e k.
3. W he n ave rbalapprovalis give n, the au thorization nu m be r m u s t be provide d within one
bu s ine s s d ay to the ons ite s c
he d u le r.
4. W he n a s c
he d u le d rou tine appointm e nt c
annot be obtaine d within 30 d ays , a loc
al
re s ou rc
e m u s t be u tilize d .
5. Sc
he d u lings hou ld be bas e d on u rge nc
y. U rge nt appointm e nts m u s t be ac
hieve d within
10d ays ;ife m e rge nt, the re s hou ld be no c
olle gialre view and the re s hou ld be im m e d iate
s e nd ou t. R ou tine appointm e nts s hou ld oc
c
u rwithin 30d ays .
31
6. W he n the patient re c
e ive s the s e rvic
e , the pape rwork and the patient m u s t be re tu rne d to
the appropriate nu rs ingare as o that the nu rs e c
an id e ntify what the ne e d s are .
7. W he n the patient re tu rns withou t are port, as taff m e m be r s hou ld be as s igne d to c
ontac
t
offs ite s e rvic
e s and obtain are port.
8. E ithe r a nu rs e or the s c
he d u le r m u s t be as s igne d re s pons ibility for retrievingoffs ite
s e rvic
e pape rwork tim e ly and this s hou ld be d oc
u m e nte d in the offs ite s e rvic
e trac
king
log.
9. N u rs e s s hou ld c
ontac
tc
linic
ians forany ord e rs .
10. W he n patients are s c
he d u le d forappointm e nts , the y s hou ld be pu t on ahold foras longas
c
linic
ally ne c
e s s ary to c
om ple te the appointm e nt be fore be ingtrans fe rre d .
11. W he n the pape rwork is obtaine d , an appointm e nt withthe ord e ringc
linic
ian or M e d ic
al
D ire c
torm u s t be s c
he d u le d within one we e k.
12. T hat e nc
ou nte r be twe e n the patient and the c
linic
ian m u s t c
ontain d oc
u m e ntation of a
d isc
Infirmary
E ac
hfac
ility has an are ad e s ignate d as an infirm ary within the he althc
are u nit e xc
e pt the N R C .
To c
larify, the N R C has an are ad e s igne d and c
ons tru c
te d as an infirm ary bu t has c
hos e n to not
u tilize the are a s inc
e ope ning. A s a re s u lt, inm ate s c
onfine d in the N R C are m ove d to the
State ville infirm ary whe n that le ve lofc
are is re qu ire d .
E ac
hofthe infirm aries is s taffe d withat le as t one re giste re d nu rs e 24 hou rs ad ay, s e ve n d ays a
we e k with the e xc
e ption ofD ixon, whe n one 11 pm to 7 a.m . s hift e ve ry two we e ks is s taffe d
withalic
e ns e d prac
tic
alnu rs e . It is ou rre c
om m e nd ation that allinfirm aries are s taffe d 24hou rs
ad ay, s e ve n d ays awe e k withat le as t one re giste re d nu rs e available whe n patients are pre s e nt.
It was obs e rve d the re was no s e c
u rity s taff pre s e nc
e in the State ville and D ixon infirm aries .
Se c
u rity s taff we re pos te d ou ts id e the u nit and m ad e rou tine rou nd s throu gh the infirm ary;
howe ve r, in the e ve nt ofas e c
u rity e m e rge nc
y, s e c
u rity s taffwou ld have to be c
alle d to re port to
the u nit. It is ou rre c
om m e nd ation that at le as t one s e c
u rity s taffm e m be rs hou ld be pos te d in the
infirm ary at alltim e s .
O u r re view of infirm ary c
are re ve ale d d e fic
ienc
ies withre gard to polic
y, prac
tic
e and phys ic
al
plant iss u e s . In te rm s ofpolic
y iss u e s , pe rhaps the m os t glaringis the lac
k ofad e s c
ription ofthe
sc
ope ofs e rvic
e s that c
an s afe ly be provid e d in the infirm ary s e tting. W e e nc
ou nte re d nu m e rou s
e xam ple s of patients who we re ad m itte d to the infirm ary with pote ntially or ac
tu ally u ns table
c
ond itions whic
h s hou ld have be e n re fe rre d to ahighe r le ve lof c
are (i.e ., ou ts id e hos pital). In
s e ve ralins tanc
e s , this re s u lte d in ac
tu alharm to the patients .
For e xam ple at M e nard , P atient [REDACTED] had ahistory ofc
irrhos is and was ad m itte d to the
infirm ary with re c
u rre nt ac
tive GI ble e d ing. D e s pite e vid e nc
e of s u bs tantial blood los s , the
patient was not s e nt to the hos pitalu ntilthe followingd ay;he d ied at the hos pitaltwo d ays late r.
A t Illinois R ive r, P atient [REDACTED] was ad m itte d to the infirm ary with rapid ly progre s s ive
paralys is ofthe lowe rhalfofhis bod y. D e s pite his re qu e s ts to be s e nt to the hos pitalbe c
au s e he
32
c
ou ld not m ove his le gs, he was ke pt in the infirm ary for two we e ks , u ntil finally a nu rs e
inte rve ne d on his be halfand appe ale d to the d oc
torfortrans fe rto the e m e rge nc
y d e partm e nt. H e
was fou nd to have le u ke m iainvolvinghis s pine and is now pe rm ane ntly whe e lc
hairbou nd .
In anothe rc
as e at Illinois R ive r, P atient [REDACTED], a37-ye ar-old d iabe tic
, was ad m itte d to the
infirm ary with s ym ptom s highly s u gge s tive of an ac
u te s troke . D u ringhis infirm ary s tay, he
c
ontinu e d to have ne u rologice pisod e s re s u ltingin profou nd we akne s s and inability to fu nc
tion
ind e pe nd e ntly, ye t was ne ve rs e nt to an ou ts ide hos pitalforprope rd iagnos is ortre atm e nt.
W e xford polic
y m ake s re c
om m e nd ations as to c
linic
als c
e narios whic
hc
ou ld be ad m itte d to the
infirm ary and thos e whic
h s hou ld not be ad m itte d (i.e ., s hou ld be re fe rre d to ahighe r le ve lof
c
are ). W hile the s e re c
om m e nd ations are agood bas is u pon whic
h to gu ide c
linic
al d e c
isionm aking, the s e c
rite riawou ld be s tre ngthe ne d by c
larifyingthat patients who are pote ntially or
ac
tu ally u ns table s hou ld be re fe rre d to an ou ts ide hos pital. Stabilitys hou ld be d e fine d to som e
d e gre e , fore xam ple , by vitals ign param e te rs , m e ntals tatu s c
rite ria, e tc
.
It s hou ld be m e ntione d he re that d u ringou r s ite visits , whe n s taff we re as ke d to prod u c
e the
polic
y gove rninginfirm ary c
are , the only d oc
u m e nt that was offe re d at any ofthe s ite s was the
ID O C A D O ffe nd e r Infirm ary Se rvic
e s d ate d 9/1/2002. T his d oc
u m e nt d iffe rs in im portant
ways from the W e xford polic
y m e ntione d above , e s pe c
ially withre s pe c
t to the c
are ofpatients
u nd e robs e rvation s tatu s orte m porary plac
e m e nt. U nd e rthe ID O C policy, patients plac
e d in the
infirm ary by nu rs ings taff for 23-hou r obs e rvation d o not re qu ire e valu ation by ac
linic
ian for
ad m iss ion or d isc
harge and the re is no re qu ire m e nt for follow u p afte r the y are re le as e d to the
c
e llhou s e s . In fac
t, it m ake s no m e ntion offollow-u pc
are forpatients ad m itte d to the infirm ary
e ithe r. In c
ontras t, the W e xford infirm ary polic
y s tipu late s that allpatients plac
e d on 23-hou r
obs e rvation have ad m iss ion ord e rs by the phys ic
ian as we llas an ad m it note and c
hart re view,
am ongothe r re s pons ibilities . T his is c
le arly not happe ningat any ofthe ins titu tions we visite d .
T he two polic
ies we re s im ilar in that ne ithe r re qu ire d a follow-u p visit for patients afte r
d isc
harge from the infirm ary.
State ville , P ontiac
, D ixon, Logan and M e nard infirm aries have no or only apartial nu rs e c
all
s ys te m , and the re is not d ire c
t line -of-s ight from the nu rs ings tation into e ac
hroom . D ixon has a
c
all s ys te m for s om e be d s bu t not for othe rs . A be ll is provid e d that the patient c
an ring;
howe ve r, ifthe patient d rops orc
annot get to the be ll, he c
annot c
allforas s istanc
e . A t the othe r
fac
ilities , apatient m u s t ye llor be at on the d oor to get som e one
s atte ntion. H ill and Illinois
R ive r C orre c
tional C e nte rs have a nu rs e c
all s ys te m for e ac
h be d in the infirm ary. It is ou r
re c
om m e nd ation that as ys te m is provid e d whic
hallows e ac
hpatient in the infirm ary to gain the
atte ntion ofnu rs ings taff.
A re view of nu rs ing infirm ary d oc
u m e ntation ind ic
ate d , ge ne rally, the re c
ord s c
ontaine d
phys ic
ian and nu rs ingad m iss ion d oc
u m e ntation, patients we re c
las s ified as c
hronicorac
u te and
d oc
u m e ntation was provide d m ore fre qu e ntly than re qu ire d . D oc
u m e ntation was in the
Su bje c
tive -O bje c
tive -A s s e s s m e nt-P lan (SO A P ) form at as re qu ire d by the D e partm e nt of
C orre c
tions O ffic
e ofH e althSe rvic
e s . V itals igns , intake and ou tpu t, and we ights we re re c
ord e d
as ord e re d by the phys ic
ian forthe ac
u te c
are patients and pu rs u ant to d e partm e nt polic
y forthe
c
hronicc
are patients . M e d ic
ations we re d oc
u m e nte d on e ac
h patient s pe c
ificm e d ic
ation
33
ad m inistration re c
ord . It was obs e rve d that the qu ality of the d oc
u m e ntation for c
hronicc
are
patients d e c
re as e d ove rtim e and be c
am e le s s and le s s m e d ic
ally inform ative .
It was obs e rve d at State ville , D ixon and P ontiacthat the infirm ary be d d ingline ns we re in s hort
s u pply and ofpoorqu ality, in that be d d ing, towe ls and was hc
loths we re torn and fraye d .
Recommendations:
1. It is ou r opinion a re giste re d nu rs e s hou ld be re ad ily available to ad d re s s infirm ary
patient iss u e s as ne e d e d .
2. In the large fac
ilities , s u c
h as State ville , P ontiacand M e nard , whe re m e d ic
al s taff is
as s igne d to work in m u ltiple bu ild ings/c
e ll hou s e s ou ts ide the m ain he alth c
are u nit
whe re the infirm ary is loc
ate d , it is re c
om m e nd e d at le as t one re giste re d nu rs e is as s igne d
at alltim e s to the bu ild ingwhe re the infirm ary is loc
ate d .
3. A t allothe r fac
ilities , it is re c
om m e nd e d at le as t one re giste re d nu rs e is as s igne d to e ac
h
s hift.
4. T he infirm ary polic
y s hou ld inc
lu d e s pe c
ificc
linic
al c
rite riawhic
h are appropriate for
infirm ary c
are , and thos e c
rite riawhic
h e xc
e e d the le ve l of c
are whic
hc
an s afe ly be
provide d in an infirm ary s e ttingand wou ld ind ic
ate re fe rralto the hos pital.
y s hou ld provid e c
rite riaou tliningwhe n patients are s table e nou ghto
be d isc
harge d from the infirm ary and re qu ire follow u pafte rinfirm ary d isc
harge .
6. D e ve lopand im ple m e nt aplan to ope n and ope rate the N R C infirm ary.
7. D e ve lopand im ple m e nt aplan to ins u re ac
ons tant s e c
u rity pre s e nc
e in the infirm ary.
8. D e ve lop and im ple m e nt aplan to ins u re e ac
h infirm ary patient is provid e d anu rs e c
all
d e vic
e.
9. D e ve lop and im ple m e nt aplan ofte ac
hing/c
ontinu inge d u c
ation for nu rs ings taff whic
h
ad d re s s e s ac
c
u rate and inform ative d oc
u m e ntation.
10. T he inc
ons iste nc
ies be twe e n the ID O C and W e xford infirm ary polic
ies s hou ld be
re c
tified , s pe c
ific
ally re gard ingthe iss u e of23-hou rad m iss ions /te m porary plac
e m e nts .
y s hou ld c
larify fornu rs ings taffthos e c
rite riathat are appropriate for
te m porary obs e rvation vs . thos e that re qu ire e valu ation by aprovid e r prior to re le as e
from the infirm ary.
12. E ns u re that ins titu tions withinfirm aries have at le as t one re giste re d nu rs e available ons ite
24hou rs ad ay, s e ve n d ays awe e k.
y s hou ld re qu ire follow u pafte rd isc
harge from the infirm ary.
14. D e ve lop and im ple m e nt aplan to ins u re s u ffic
ient qu ality and qu antities of infirm ary
be d d ingand line ns .
Infection Control
Infe c
tion c
ontrol is a m oving targe t ac
ros s the s ys te m , with s om e fac
ilities having we ll
d e ve lope d program s withothe rs in the ir infanc
y. P art ofthe proble m is the pos ition ofInfe c
tion
C ontrolN u rs e (R N )is viewe d as an ad d -on orad d itionald u ties rathe rthan as e parate and d istinc
t
jobd e s c
ription withve ry s pe c
ificfu nc
tions . Ju s t afe w ofthe jobd u ties foran Infe c
tion C ontrol
N u rs e wou ld be :
34
1. D e ve lop, im ple m e nt and m anage the e m ploye e and inm ate T B te s tingand s u rve illanc
e
program .
2. C ond u c
t m onthly d oc
u m e nte d s afe ty and s anitation ins pe c
tions foc
u s ingat am inim u m
on the he alth c
are u nit, d ietary d e partm e nt and c
e ll hou s e s /hou s ingu nits with m onthly
re portingto the Q u ality Im prove m e nt C om m itte e (Q IC ).
3. D e ve lop and im ple m e nt aplan to m onitor food hand le r e xam inations and c
le aranc
e for
d ietary s taffand inm ate food worke rs .
4. D e ve lopand im ple m e nt aplan to aggre s s ive ly m onitors kin infe c
tions and boils and work
jointly with s e c
u rity and m ainte nanc
e s taff re gard ingc
e llhou s e c
le aningprac
tic
e s with
m onthly re portingto the Q IC and fac
ility ad m inistration as ne e d e d .
5. Inte rfac
e with and re port as ne e d e d to the C ou nty D e partm e nt of P u blicH e alth and
Illinois D e partm e nt ofP u blicH e alth.
6. D e ve lop and im ple m e nt a plan to d aily m onitor and d oc
u m e nt ne gative air pre s s u re
re ad ings in the d e s ignate d re s piratory isolation room s whe n the room s are be ingoc
c
u pied
forre s piratory isolation pu rpos e s and we e kly whe n not.
7. M onitoralls ic
kc
allare as to as s u re appropriate infe c
tion c
ontrolm e as u re s are be ingu s e d
be twe e n patients i.e ., u s e of a pape r barrier on e xam ination table s whic
h is c
hange d
be twe e n patients oras pray d isinfe c
tant is u s e d be twe e n patients , e xam ination glove s and
othe r pe rs onal prote c
tive e qu ipm e nt is always available to staff and hand
was hing/sanitizingis oc
c
u rringbe twe e n patients .
In ord e rforthe infe c
tion c
ontrolnu rs e to pe rform allthe re s pons ibilities to whic
hthe ID O C has
agre e d , it is the opinion this wou ld re qu ire atim e c
om m itm e nt ofat le as t 25% ofthe ind ivid u als
tim e re s u lting in 10 hou rs a we e k e qu aling two hou rs a d ay d e vote d to infe c
tion c
ontrol
ac
tivities .
A nothe r iss u e is that the re is no O ffic
e ofH e althSe rvic
e s ove rs ight s inc
e the re tire m e nt ofthe
C om m u nic
able and Infe c
tiou s D ise as e s C oord inator and the pos ition has ne ve r be e n fille d .
Ge ne rally, fac
ilities are provid ing tu be rc
u los is te sting and s u rve illanc
e , H IV te sting and
tre atm e nt, food hand le re xam inations and c
le aranc
e.
A c
ros s all s ite s , infirm ary line ns we re not be ingappropriate ly lau nd e re d and s anitize d d u e to
be inglau nd e re d in re s id e ntials tyle was hingm ac
hine s loc
ate d in the he althc
are u nit and wate r
te m pe ratu re s d id not re ac
has u ffic
iently highe nou ghte m pe ratu re nor was ble ac
hu s e d in ord e r
to re nd e rthe line ns s anitize d . W hile the N C C H C s tand ard s d o not s pe c
ific
ally ad d re s s infirm ary
line n lau nd e ringte m pe ratu re s , the O ffic
e ofH e althSe rvic
e s E xpos u re C ontrolM anu aland the
ID O C A d m inistrative D ire c
tive 05.02.140 d o be c
au s e of the ne e d to hand le infirm ary be d d ing
and line ns d iffe re ntly than ge ne ral popu lation be d d ingand line ns . A ll infirm ary be d d ingand
line ns m u s t be tre ate d as thou gh the y are c
ontam inate d be c
au s e the re is no way to ins u re that
the y are not. A s are s u lt, the y m u s t be lau nd e re d pu rs u ant to C e nte rs forD ise as e C ontrol(C D C )
gu ide line s to pre ve nt c
ros s c
ontam ination/infe c
tion ofpatients . T he wate rte m pe ratu re gu id e line s
as ou tline d in A .D . 05.02.140c
om ply withthe C D C gu ide line s .
W iththe e xc
e ption ofthe N orthe rn R e gion R e c
e ption C e nte rwhic
hhas no infirm ary at pre s e nt,
allthe othe rfac
ilities ins pe c
te d we re lau nd e ringthe irinfirm ary be d d ingand line ns in re s id e ntial
s tyle was hingm ac
hine s loc
ate d in the infirm ary. W ate r te m pe ratu re s m e as u re d at e ac
h of the
35
fac
ilities , othe r than the N R C , we re we ll be low the m inim u m te m pe ratu re of 140 d e gre e s
Fahre nhe it. A d d itionally, as re porte d by the fac
ility at the tim e of the ins pe c
tion, hot wate r
te m pe ratu re s in the Illinois R ive rins titu tionallau nd ry we re m e as u re d at 125d e gre e s Fahre nhe it.
Ifthe infirm ary be d d ingand line ns had be e n lau nd e re d in the ins titu tion lau nd ry, the hot wate r
te m pe ratu re s tillwou ld not have be e n s u ffic
ient to d e c
ontam inant the be d d ingand line ns .
It is re c
om m e nd e d , in ord e r to pre ve nt c
ros s c
ontam ination/infe c
tion of patients , infirm ary
be d d ingand line ns be lau nd e re d pu rs u ant to the gu ide line s d e taile d in the ID O C A d m inistrative
D ire c
tive 05.02.140.
In large c
ongre gate hou s ings e ttings the re is an inc
re as e d risk ofrapid d e ve lopm e nt ofou tbre ak
of infe c
tions . T he inm ate popu lation is c
u rre ntly at risk and will c
ontinu e to be at risk if the
infe c
tion c
ontrolre c
om m e nd ations are not ad opted and im ple m e nte d . T he re is not c
u rre ntly, nor
has the re be e n fors om e pe riod oftim e , any ID O C ove rs ight and m anage m e nt ofas ys te m -wid e
infe c
tion c
ontrolprogram . W hile e ac
hfac
ility has be e n provid e d an infe c
tion c
ontrolm anu al, the
m anu al was d e ve lope d s e ve ral ye ars ago, and the ID O C O ffic
es
C om m u nic
able D ise as e C oord inatorpos ition is vac
ant and has be e n vac
ant fors om e tim e . A s a
re s u lt, fac
ilities are d oing the ir own thing in re gard to infe c
tiou s d ise as e s u rve illanc
e,
m onitoringand re porting. N ot allthe fac
ilities have ad e s ignate d Infe c
tion C ontrolR N and , as a
re s u lt, the re s pons ibility is ad d e d to the d u ties of e ithe r the H e alth C are U nit A d m inistrator or
D ire c
torofN u rs ing, ne ithe r ofwhom has the tim e to ad e qu ate ly d o the job. Forthos e fac
ilities
that have d e s ignate d a s pe c
ificR N as infe c
tion c
ontrol nu rs e , s om e have d e ve lope d a job
d esc
ription with s pe c
ificre s pons ibilities and othe r fac
ilities have not. M ore im portantly,
ind ivid u als have not be e n provide d trainingto know how to ru n an e ffe c
tive infe c
tion c
ontrol
program . W hile the re is a re c
ognize d O ffic
e s E xpos u re C ontrol M anu al,
d u ringthe c
ou rs e of the ins pe c
tions , the fac
ilities re porte d the re was no trainingprovide d to
he althc
are u nit/infirm ary inm ate porte rs at D ixon, Illinois R ive r, M e nard , P ontiacand State ville .
A d d itionally and as re porte d by the fac
ility, the re was no infe c
tion c
ontrolprogram in plac
e at
the N orthe rn R e gion R e c
e ption C e nte r.
T he O ffic
e s E nvironm e ntal H e alth C oord inator has d e ve lope d and
im ple m e nte d gu ide line s for the appropriate lau nd e ring and s anitizing of infirm ary line ns ;
howe ve r, the fac
ilities are not followingthe gu id e line s . Infirm ary line ns are be ingwas he d in
re s ide ntials tyle was hingm ac
hine s loc
ate d within the he althc
are u nit and wate rte m pe ratu re s are
not be ingm onitore d . A t s e ve ralofthe fac
ilities , the wate r te m pe ratu re s we re not hot e nou ghto
m e e t the re qu ire m e nts to prope rly s anitize infirm ary line ns . A s are s u lt, the re is the pote ntialfor
e xpos u re and c
ros s -c
ontam ination be twe e n patients as a re s u lt of im prope rly s anitize d be d
line ns .
W ith the e xc
e ption of the N R C , all the fac
ilities have ne gative air pre s s u re room s to isolate
patients withs u s pe c
te d re s piratory infe c
tions withthe e m phas is be ingon tu be rc
u los is infe c
tion.
T his be ings aid, not allthe fac
ilities have as ys te m in plac
e to ins u re the room s are at ne gative
pre s s u re , e s pe c
ially whe n apatient on re s piratory isolation pre c
au tions is plac
e d in one of the
room s . Sim ilarly, not allthe room s have alarm s , both au d ible and visu al, to ale rt pe rsonne l if
ne gative airpre s s u re has be e n los t.
36
It was obs e rve d at s e ve ral fac

ilities that infirm ary m attre s s e s , e xam ination table s and othe r
e qu ipm e nt was in poorre pair, in that the plas ticprote c
tive c
ove ringwas c
rac
ke d ortorn, m aking
it im pos s ible to prope rly s anitize the ite m s be twe e n patients . T he s e ite m s ne e d to be re paire d or
take n ou t of s e rvic
e , bu t no one is m onitoringe qu ipm e nt to ins u re it is in good c
ond ition.
A d d itionally, it was obs e rve d at s e ve ralfac
ilities that the re was e ithe r no u s e ofapape r barrier
on e xam ination table s whic
hc
ou ld be e as ily c
hange d be twe e n patients or c
le aningof table
s u rfac
e s be twe e n patients . A gain, this wou ld be apart ofthe infe c
tion c
ontrolnu rs e
s d u ties to
m onitorand provide c
orre c
tive ac
tion whe n ne e d e d .
T he s e are ju s t afe w e xam ple s ofthe s ys te m iciss u e s d u e to the lac
k ofc
e ntraloffic
e ove rs ight
and m anage m e nt of an infe c
tion c
ontrol program and whic
h re s u lte d in the infe c
tion c
ontrol
re c
om m e nd ations .
Recommendations:
1. E ac
hfac
ility is to d o the following:
a. D e ve lop a pos ition d e s c
ription and nam e an Infe c
tion C ontrol (IC )/Q u ality
Im prove m e nt (Q I) re giste re d nu rs e (IC /Q I-R N ) and provide training on
c
om m u nic
able and infe c
tiou s d ise as e re c
ognition, m onitoringand re porting, and the
Q u ality Im prove m e nt proc
ess.
b. D e ve lop and im ple m e nt aplan for the IC /Q I-R N to c
ond u c
t m onthly d oc
u m e nte d
s afe ty and s anitation ins pe c
tions foc
u s ingat a m inim u m on the he alth c
are u nit,
infirm ary and d ietary d e partm e nt withm onthly re portingto the Q u ality Im prove m e nt
C om m itte e (Q IC ).
c
. D e ve lop and im ple m e nt a plan for the IC /Q I-R N to m onitor food hand le r
e xam inations and c
le aranc
e fors taffand inm ate s .
d . D e ve lop and im ple m e nt aplan for the IC /Q I-R N to m onitor c
om plianc
e with initial
and annu al tu be rc
u los is s c
re e ning, with m onthly re portingto the Q IC and fac
ility
ad m inistration as ne e d e d .
e . D e ve lop and im ple m e nt aplan to aggre s s ive ly m onitor s kin infe c
tions and boils and
work jointly with s e c
e s taff re gard ing c
e ll hou s e c
le aning
prac
tic
e s withm onthly re portingto the IC /Q I-R N , Q IC and fac
ility ad m inistration as
ne e d e d .
f. D e ve lop and im ple m e nt aplan to d aily m onitor and d oc
re ad ings whe n the room (s )is oc
c
u pied forre s piratory isolation and we e kly whe n not
oc
c
u pied .
g. D e ve lopand im ple m e nt atrainingprogram forhe althc
are u nit porters whic
hinc
lu d e s
trainingon blood -borne pathoge ns , infe c
tiou s and c
om m u nic
able d ise as e s , bod ily
flu id c
le an-u p, prope r c
le aningand s anitizingof e qu ipm e nt, infirm ary room s , be d s ,
fu rnitu re , toile ts and s howe rs .
h. M onitor alls ic
kc
allare as to ins u re appropriate infe c
tion c
ontrolm e as u re s are be ing
u s e d be twe e n patients i.e ., u s e of pape r on e xam ination table s whic
h is c
hange d
be twe e n patients oras pray d isinfe c
tant is u s e d be twe e n patients , e xam ination glove s
are available to staffand hand was hing/sanitizingis oc
c
i. D e ve lop and im ple m e nt a plan to m onthly m onitor all patient c
are as s oc
iate d
fu rnitu re , inc
lu d inginfirm ary m attre s s e s , to as s u re the inte grity ofthe prote c
tive ou te r
s u rfac
e withthe ability to take ou t ofs e rvic
e and have re paire d orre plac
e d as ne e d e d .
37
j. Inte rfac
e with the C ou nty D e partm e nt of H e alth and Illinois D e partm e nt of H e alth
and provide re portingas re qu ire d by e ac
h.
k. D e ve lopand im ple m e nt aplan forthe prope rs anitizingofhe althc
are u nit line ns .
2. T he O ffic
e s to fill the pos ition of s tate wide C om m u nic
able and
Infe c
tiou s D ise as e s C oord inator.
Dental Program
W hile an e xe c
u tive s u m m ary is available for ind ivid u al ins titu tions , this re port ad d re s s e s the
program we akne s s e s ofthe ID O C program as awhole . C onc
e rns e m e rge whe n am ajority ofthe
ins titu tions are d e fic
ient in the s tand ard re viewe d . E s pe c
ially e gre giou s prac
tic
e s and /or
om iss ions are als o m e ntione d in this re port.
Access to Care
Orientation and Access to Care
A c
c
e s s to c
are was inad e qu ate ly d e taile d ornot m e ntione d at allin the m ajority ofthe orientation
m anu als re viewe d . Inm ate s d o not re c
e ive ad e qu ate ins tru c
tions on how to ac
c
e s s u rge nt or
rou tine c
are .
Dental Sick Call Procedures
T he lag tim e be twe e n an Inm ate R e qu e s t Form for pain and alle viation of the pain was
u nac
c
e ptable . It ofte n took fou rorm ore d ays foru rge nt c
are patients to be s e e n. P atients who are
in pain s hou ld be able to ac
c
ess c
are within 24-48hou rs .
Broken Appointments
T he broke n appointm e nt rate was above 10% at s e ve ralins titu tions and as highas 40% at thre e
ins titu tions . T he latte rare alarm ingrate s .
Quality of Care
Screenings and Examinations
A lthou gh a re view of re c
ord s re ve ale d that the ID O C was in c
om plianc
e with its s c
re e ning
e xam ination polic
y, oralhe althins tru c
tions are om itte d as part ofthe proc
e s s . R athe r e gre giou s
d e fic
ienc
ies we re obs e rve d at the N R C d u ringthe s c
re e ninge xam . T he e xam was e xtre m e ly
c
u rs ory and d id not inc
lu d e an ad e qu ate he ad and ne c
k and s oft tiss u e e xam ination. T he he alth
history was s ke tc
hy and poorly d oc
u m e nte d . R ad iology s afe ty protoc
ols we re non-e xiste nt. A re a
d isinfe c
tion and c
linic
ian hygiene be twe e n patients was ve ry poor. Inappropriate ly, m os t d e ntists
u s e this e xam , the panoram icrad iograph and the c
hartingas atre atm e nt plan from whic
h to
d e live rrou tine c
are .
Routine Care
A re view of re c
ord s at e ac
h ins titu tion re ve ale d that rou tine c
are was alm os t always provid e d
withou t ac
om pre he ns ive e xam ination, atre atm e nt plan, ad oc
u m e nte d pe riod ontalas s e s s m e nt, a
d oc
u m e nte d s oft tiss u e e xam ination, and withou t bite wings or othe r rad iographs d iagnos ticfor
c
aries . A ls o, the re was s e ld om ad e ntalprophylaxis or oralhe althins tru c
tions provide d prior to
re s torative c
are . W ithou t the s e bas ice le m e nts in plac
e , qu ality rou tine c
are is alm os t im pos s ible .
A s su c
h, the re is no re als ys te m in plac
e to provid e rou tine c
om pre he ns ive C ate gory 3 d e ntal
c
are .
38
Removable Partial Dentures

A re view of re c
ord s re ve ale d that prior to c
ons tru c
tion of re m ovable partial d e ntu re s , oral
hygiene e d u c
ation and d e ntal prophylaxis we re s e ld om provid e d , the pe riod ontiu m was not
d oc
u m e nte d to be s table and re s torative c
are was provide d from inad e qu ate tre atm e nt plans .
P rope r rad iographs we re s e ld om pre s e nt. T he rad iographs and e xam inations /tre atm e nt plans
we re s o inc
om ple te orvagu e that it c
ou ld not be d e te rm ine d ifallne c
e s s ary c
are was c
om ple te d
priorto im pre s s ions .
Dental Extractions
A lthou ghthe nu m be r was re lative ly s m all, ad e qu ate rad iographs we re at tim e s not available . A
fe w re c
ord s had no pre -e xtrac
tion rad iographs at all. A prope r d iagnos ticre as on for e xtrac
tion
was s e ld om part ofthe d e ntalre c
ord . D oc
u m e ntation was , ove rall, ve ry poor. In one ins titu tion,
c
ons e nt for tre atm e nt form s we re not in u s e . A ntibiotic
s we re provide d rou tine ly afte r d e ntal
e xtrac
tions at ac
ou ple ofins titu tions .
Continued Quality Improvement
T he d e ntalc
ontribu tion u s u ally was lim ite d to m onthly s tatistic
s . M ost d e ntalprogram s had no
s tu d ies , as s e s s m e nts or s u bs e qu e nt im prove m e nts in plac
e . T he re is no pe e r re view proc
e s s in
plac
e within the ID O C d e ntalprogram . T he re is little d ire c
tion or m e aningfu love rs ight of the
ID O C d e ntalprogram to ins u re that prope rpolic
ies and protoc
ols are in plac
e and followe d , and
that d e ntals tand ard s ofc
are are prac
tic
ed .
Health History Documentation
T he m e d ic
alhe althhistory s e c
tion ofthe d e ntalre c
ord was s ketc
hy and inc
om ple te . C ond itions
that re qu ire m e d ic
alatte ntion we re not re d flagge d . M e d ic
alc
ons u ltations we re not d oc
u m e nte d
in the d e ntalre c
ord . T he qu ality and c
ons iste nc
y ofthe m e d ic
alhistory in the d e ntalre c
ord was
inad e qu ate . B lood pre s s u re s we re not be ingtake n on inm ate s withahistory ofhype rte ns ion.
SOAP Format
T he SO A P form at was not be ingu s e d to d oc
u m e nt C ate gory 1and 2patient e nc
ou nte rs .
Dental Policy and Protocol Manuals
Ins titu tionalP olic
y and P rotoc
olM anu als we re u s u ally ve ry inc
om ple te , ou td ate d , ornot pre s e nt
at all. D e ntalprogram s we re im ple m e nte d and m anage d withfe w gu id e line s and little ove rs ight.
T he ID O C A d m inistrative D ire c
tive s are inc
om ple te and provide little in the way ofgu id anc
e on
d e ve lopingand m anagingas u c
c
e s s fu ld e ntalprogram .
Physical Resources
Adequacy of Equipment
M uc
h of the e qu ipm e nt was old , c
orrod e d and bad ly worn. C abine try and c
ou nte rtops we re
u s u ally bad ly worn, c
orrod e d or ru ste d , broke n and not u p to c
onte m porary s tand ard s for
d isinfe c
tion. N on-fu nc
tionale qu ipm e nt was not ou t ofthe norm .
Human Resources
Dental Clinic Staffing
39
M os t s taffingwas ad e qu ate and in c

om plianc
e withA d m inistrative D ire c
tive 04.03.102, Se c
tion
9, a. b. c
. Glaringom iss ions we re the lac
k ofd e ntalhygienists at D ixon C C and H e nry H illC C .
D e ntalhygienists are an e s s e ntialpart ofthe d e ntalte am .
Safety and Sanitation
In s e ve ralins titu tions , prope rs te rilization flow was not in plac
e . A t one ins titu tion, s pore te sting
ofthe au toc
lave s was be ingpe rform e d m onthly rathe r than we e kly. A t anothe r ins titu tion, bu lk
s torage of biohaz ard ou s was te was m aintaine d in the d e ntal c
linicprope r in ope n, large
c
ard board boxe s on palate s . In none ofthe c
linic
s we re the s te rilization are aand the rad iology
are aposte d withprope rhaz ard warnings igns . Safe ty glas s e s we re s e ld om worn by patients .
Dental Program Management
T he A d m inistrative D ire c
tive s are ins u ffic
ient. T he y d o not ad d re s s qu ality ofc
are iss u e s , c
linic
m anage m e nt, re c
ord m anage m e nt ors taffove rs ight and re s pons ibilities . D e ntist are provide d no
orientation to the ID O C d e ntalprogram ortrainingon how to m anage the irins titu tion program s .
T his, in c
onju nc
tion with inad e qu ate qu ality as s u ranc
e and pe e r re view, s u gge s ts a lac
k of
ove rs ight on the part ofthe ID O C . T he re is not an ad m inistrative d e ntist to ove rs e e and m anage
the ID O C d e ntalprogram .
T he policy m and atingbiennialrou tine e xam inations d oe s not s e e m be ne fic
ial. It take s u pagre at
d e alof ad m inistrative tim e . Inm ate s have fu ll ac
c
e s s to d e ntalc
are . D e ntists s hou ld u s e the ir
tim e provid ingthis c
are , e s pe c
ially in light ofthe d e ntals taffinggu id e line s .
Dental Care Recommendations:
Orientation and Access to Care
1. T he ID O C d e ve lop apolic
y to ins u re that e ac
h ins titu tion has am e aningfu lorientation
m anu alto ins tru c
t inm ate s how to ac
c
e s s ac
u te and rou tine c
are .
Dental Sick Call Procedures
1. Ins u re that inm ate s withu rge nt c
are ne e d s be provid e d c
are within 24-48hou rs .
2. T hat the SO A P form at be u s e d to d oc
u m e nt e m e rge nc
y and u rge nt c
are c
ontac
ts .
Broken Appointments
1. T he ID O C d e ve loppolic
ies and ove rs ight to ad d res s broke n appointm e nt rate s ove r10%.
Screening Examinations
1. Sc
re e ninge xam inations at the re c
e ption c
e nte rinc
lu d e athorou gh, d oc
u m e nte d intraand
e xtra-orals oft tiss u e e xam ination.
2. T he he althhistory be m ore c
om pre he ns ive and appropriate c
ond itions re d flagge d .
3. P rope rare ad isinfe c
tion and c
linic
ian hygiene be im ple m e nte d .
4. P rope rrad iology hygiene be pu t in plac
e.
5. T hat this s c
re e ninge xam not be u s e d to d e ve loptre atm e nt plans .
Routine Care
40
1. R ou tine c
om pre he ns ive c
are be provide d from a thorou gh c
om pre he ns ive e xam and
tre atm e nt plans .
2. T hat the e xam inc
lu d e s rad iographs d iagnos ticforc
aries , ape riod ontalas s e s s m e nt, as oft
tiss u e e xam and ac
c
u rate c
hartingofthe te eth.
3. T hat hygiene c
are and oral he alth ins tru c
tions be provid e d as part of the tre atm e nt
proc
ess.
Removable Partial Dentures
1. T hat re m ovable partiald e ntu re s be provid e d as the las t s te p in the c
om pre he ns ive c
are
proc
ess.
2. T hat allte e thare re s tore d and the pe riod ontiu m s table be fore im pre s s ions are take n.
Dental Extractions
1. C u rre nt d iagnos ticrad iographs be pre s e nt fore ve ry e xtrac
tion.
2. A d iagnos is orre as on fore xtrac
tion be part ofthe re c
ord e ntry.
3. A c
ons e nt forc
are form be u s e d fore ve ry e xtrac
tion.
4. A ntibiotic
s be pre s c
ribe d only from an appropriate d iagnos is.
Continued Quality Improvement
1. E ve ry d e ntalprogram d e ve loparobu s t and m e aningfu lC Q I program to inc
lu d e ongoing
s tu d ies and c
orre c
tive m e as u re s that ad d re s s ide ntified program we akne s s e s .
Peer Review
1. T he ID O C d e ve lopac
linic
ally oriente d pe e rre view s ys te m and that d e ntists be available
to provide the s e re views , s u c
h that d e fic
ienc
ies in tre atm e nt qu ality or appropriate ne s s
c
an be c
orre c
te d .
Health History Documentation
1. T he ID O C d e ve lop athorou ghand we lld oc
u m e nte d he alth history s e c
tion in the d e ntal
re c
ord .
2. T hat appropriate m e d ic
alc
ond itions be re d flagge d and that m e d ic
al c
ons u ltations and
pre c
au tions be d oc
u m e nte d in the d e ntalre c
ord .
Dental Policy and Protocol Manuals
1. T hat ID O C d e ntalpolic
y ins u re s that allins titu tion d e ntalprogram s have we lld e ve lope d
and thorou gh polic
y and protoc
olm anu als that ad d re s s allare as of the d e ntalprogram .
T hat alld e ntals taffbe fam iliarwiththe s e polic
ies and protoc
ols .
2. P olic
ies are re viewe d annu ally and am e nd e d as ne c
e s s ary.
3. A n ad m inistrative d e ntist be available to ove rs e e the ID O C d e ntalprogram as awhole .
T his pe rs on c
ou ld re m ain in the field as apart-tim e prac
tic
ingd e ntist.
Equipment Condition
1. A s ys te m wid e e valu ation ofe xistinge qu ipm e nt be pe rform e d and that u nd u ly old , bad ly
worn, ru ste d , c
orrod e d and non-fu nc
tionalu nits , e qu ipm e nt and c
abine try/c
ou nte rtops be
re plac
ed .
41
Dental Clinic Staffing

1. D e ntalhygienists be hire d A SA P at H e nry H illC C and D ixon C C .
Safety and Sanitation
1. T he ID O C ins u re s that alld e ntalprogram s follow c
u rre nt infe c
tion c
ontrolgu id e line s as
we ll d e fine d by the C e nte r for D ise as e C ontrol, to inc
lu d e d oc
u m e nte d we e kly s pore
te stingofau toc
lave s .
2. B u lk biohaz ard ou s was te be prope rly s tore d ou ts id e the d e ntalc
linic
.
3. B iohaz ard and rad iology warnings igns be in plac
e.
4. P atients we arprote c
tive e ye we ard u ringtre atm e nt.
Dental Program Management
1. T he ID O C e valu ate its A d m inistrative D ire c
tive s and d e ve loppolic
ies and protoc
ols that
provide m e aningfu l gu id anc
e and ove rs ight to the field on how to ru n and m anage a
su c
c
e s s fu ld e ntalprogram , to inc
lu d e allofthe iss u e s d isc
u s s e d in the bod y ofthis re port.
T he s e polic
ies s hou ld be gu id e d by arisk as s e s s m e nt proc
e s s that ins u re s s afe and we ll
e qu ippe d c
linic
s , ad e qu ate and we ll traine d d e ntal s taff, tre atm e nt provid e d c
ons iste nt
withprofe s s ionals tand ard s ofc
are and in atim e ly m anne r, and thorou ghand c
om ple te
re c
ord d oc
u m e ntation.
Mortality Reviews
T he taxonom y u s e d forthe m ortality re views is d e s c
ribe d in d e tailin the attac
he d A ppe nd ix B . It
ou tline s 14d istinc
t type s oflaps e s in c
are , withe ac
hlaps e re pre s e ntingas e riou s d e viation from
the s tand ard ofc
are . M any c
as e s had m ore than one laps e in c
are , and the s e are s pe c
ified in the
c
as e d e s c
riptions . W e c
hos e to u s e this m e thod ology whic
h was d e ve lope d by the C alifornia
P rison R e c
e ive rs hipbe c
au s e it has be e n c
e rtified by the Fe d e ralC ou rt in Plata v. Brown, ac
as e
involving ad e qu ac
y of m e d ic
al c
are in the C alifornia D e partm e nt of C orre c
tions and
R e habilitation.
T he re we re 127 d e aths within ID O C be twe e n Janu ary 1, 2013 and Ju ne 1, 2014, 10 of which
we re viole nt d e aths (s u ic
id e s orhom ic
id e s )and we re the re fore not re viewe d forthe pu rpos e s of
this re port. O fthe re m aining117m ortalities , we reviewe d 61c
as e s (52% ), plu s an ad d itionaltwo
c
as e s ofpatients who d ied in 2010, foratotalof63c
as e s . T he d e tails ofe ac
hc
as e are d e s c
ribe d
in the attac
he d A ppe nd ix B . T he re we re one orm ore s ignific
ant laps e s in c
are in 38c
as e s (60% ).
T his is an u nac
c
e ptably high rate of d e viations from the s tand ard of c
are . O f thos e c
as e s with
s ignific
ant laps e s , 34(89% )had m ore than 1.
T he inte rnalID O C m ortality re view proc
e s s is s e riou s ly flawe d , in that the re views are , for the
m os t part, pe rform e d by the d oc
tor m os t c
los e ly involve d in the c
are of the d e c
e d e nt. T his
arrange m e nt e ffe c
tive ly pre c
lu d e s an obje c
tive re view by d e finition. T his is ind e e d what we
fou nd whe n we re viewe d 20 (52% ) of the d e ath re view s u m m aries of the proble m aticd e aths
(liste d in A ppe nd ix B );in none ofthe m we re any ofthe laps e s in c
are id e ntified .
O nly afe w d e aths are re viewe d by the O ffic
e ofH e althSe rvic
e s , and the s e are s e le c
te d on the
bas is of laps e s in c
are id e ntified by the loc
alre view. A s ju s t s tate d , in none ofthe proble m atic
42
c
as e s that we re viewe d d id the fac
ility provid e rid e ntify aproble m withthe patient
sc
are , and as
are s u lt it is u nlike ly that any of the s e we re ind e pe nd e ntly re viewe d at the c
e ntraloffic
e le ve l.
O ne c
ou ld argu e that e ve n are view by O H S is not tru ly an ind e pe nd e nt re view. W e re c
om m e nd
that alld e aths be re viewe d by an ind e pe nd e nt third party to provide an u nbias e d opinion on the
qu ality ofc
are , bothfrom ac
linic
alprac
tic
e and as ys te m s pe rs pe c
tive . T hos e c
as e s id e ntified as
proble m atics hou ld the n be re viewe d by the O ffic
e ofH e althSe rvic
es.
M any of the d e aths that we re viewe d we re of patients who we re c
hronic
ally illwith te rm inal
c
ond itions . Y e t the re are no re s ou rc
e s in plac
e to as s ist he althc
are s taff in the c
are ofpatients
who are d yingorin the m anage m e nt ofc
om m on e nd oflife s ym ptom s . It was obviou s that onc
e
patients s igne d D N R (d o not re s u s c
itate ) ord e rs , the y we re ofte n no longe r tre ate d for e ve n
s im ple re ve rs ible illne s s (for e xam ple , s e e patient #42 in the attac
he d M ortality R e view
appe nd ix). E ve n thou gh D N R is an ins tru c
tion not to u s e C P R u nd e r c
irc
u m s tanc
e s whe n it is
known to be fu tile , ofte n s im ple tre atm e nt with antibiotic
s or hyd ration or s u c
tioningc
an be
e ffe c
tive and d im inish s u ffe ring. T he re s hou ld be as pe c
ificgu id e line or polic
y langu age that
d esc
ribe s hos pic
e orc
om fort c
are forte rm inally illpatients , and c
larify that d o not re s u s c
itate
d oe s not m e an, D o not tre at.
Recommendations:
1. A llm ortality re views s hou ld be pe rform e d by an ind e pe nd e nt c
linic
ian. A re gionalnu rs e
c
ou ld d o the initialre view;thos e c
as e s id e ntified as pote ntially proble m aticand the re fore
re qu iringas e c
ond ary re view s hou ld be e valu ate d by the c
e ntraloffic
e re gionalphys ic
ian,
and not alike (i.e ., W e xford )e m ploye e .
2. P olic
y s hou ld provid e m ore s pe c
ificgu id anc
e for e nd of life c
are . Spe c
ific
ally, this
s hou ld c
larify the im portant d iffe re nc
e s be twe e n D N R ,palliative c
are and hos pic
e /e nd of-life c
are .
Continuous Quality Improvement

T his is the program that is the bas is by whic
h he alth organizations , whe the r the y be in the
c
om m u nity or in c
orre c
tional fac
ilities , m e as u re and id e ntify the qu ality, proc
e s s and
profe s s ionalpe rform anc
e withre gard to m any type s ofparam e te rs . W he n that pe rform anc
e d oe s
not m e e t as e t ofe xpe c
tations attribu table to awe ll-ru n program , the re m u s t be an e ffort to le arn
the re as ons why the pe rform anc
e is not u pto stand ard and the n onc
e thos e re as ons are id e ntified ,
im prove m e nt s trate gies are d e s igne d to m itigate thos e re as ons . A we ll-ru n qu ality im prove m e nt
program looks at or re views e ve ry m ajor s e rvic
e provide d at le as t annu ally. In the typic
al
c
orre c
tionalprogram , foranon-re c
e ption c
e nte r, the re view wou ld inc
lu d e :
1.
2.
3.
4.
5.
6.
7.
8.
intras ys te m trans fe rs e rvic

es
s ic
kc
alls e rvic
e s , bothge ne ralpopu lation and loc
kd own
c
hronicd ise as e s e rvic
es
u ns c
es
sc
e s (c
e d u re s )
m e d ic
ation s e rvic
es
d e ntals e rvic
es
m e ntalhe alths e rvic
es
43
9. laboratory and x-ray s e rvic

es
10. infirm ary s e rvic
es
11. s pe c
iald iet s e rvic
es
A lthou gh this list is not m e ant to be e xhau s tive it d oe s c
onve y the type s of he alth s e rvic
es
provide d in atypic
alprison. W ith re gard to the s e s e rvic
e s , ahe alth c
are program as s e s s e s the
qu ality ofc
are provide d by u tilizingone or m ore ofe ight qu ality pe rform anc
e m e as u re s . T hos e
m e as u re s inc
lu d e :
1. ac
c
e s s ibility
2. appropriate ne s s (c
orre c
tc
linic
ald e c
ision m aking)
3. e ffe c
tive ne s s (ou tc
om e s )
4. e ffic
ienc
y
5. c
ontinu ity ofc
are
6. tim e line s s
7. s afe ty (bothavoidanc
e ofhaz ard s as we llas c
onform anc
e withc
u s tod y re qu ire m e nts )
8. qu ality ofs taff-patient inte rac
tion
In ord e rto s e lf-m onitorqu ality pe rform anc
e m e as u re s s u c
has tim e line s s orc
ontinu ity ofc
are , it
is u s e fu lif not m and atory to m aintain logs that allow the trac
kingof s ic
kc
alls e rvic
e s , u rge nt
c
are s e rvic
es, c
hronicd ise as e s e rvic
es, sc
e s , e tc
. T he s e logs fac
ilitate an
e ffic
ient re view as we llas d atac
olle c
tion withre gard to one orm ore ofthe qu ality pe rform anc
e
m e as u re s u tilize d to as s e s s the qu ality ofs e rvic
es.
T he Illinois D e partm e nt of C orre c
tions inc
lu d e s apolic
y on qu ality im prove m e nt that re qu ire s
d atac
olle c
tion withre gard to m any s e rvic
e s . A t s om e ofthe fac
ilities that we re viewe d , s u c
has
State ville , N R C and D ixon, the re had be e n ve ry little re c
e nt qu ality im prove m e nt ac
tivity ove r
the priors ix to twe lve m onths . In othe rfac
ilities , althou ghs om e d atawas c
olle c
te d it was ne ve r
u s e d to m e as u re pe rform anc
e agains t s tand ard s and the re fore was not part ofan e ffort to m e as u re
the qu ality of the pe rform anc
e . It is e xpe c
te d that d u ringthe c
ou rs e of aye ar e ve ry s e rvic
e is
as s e s s e d withre gard to one orm ore ofthe e ight qu ality pe rform anc
e m e as u re s .
W e we re u nable to find , in any of the e ight ins titu tions we re viewe d , d oc
u m e ntation of s u c
h
m e as u re m e nt. O nly afte r s u c
h m e as u re m e nt has oc
c
u rre d and whe n the d ata ind ic
ate s the
pe rform anc
e is not ad e qu ate c
an the re be an analys is of the re as ons for the inad e qu ate
pe rform anc
e . T he n tailore d im prove m e nt s trate gies c
an be im ple m e nte d to m itigate the re as ons
for the s u bs tand ard pe rform anc
e . In none ofthe e ight s e ts of m inu te s that we re viewe d d id we
find anythingre m ote ly re late d to e fforts to im prove the qu ality of the program . A d d itionally,
alm os t none ofthe as s igne d qu ality im prove m e nt c
oord inators had any form altrainingin qu ality
im prove m e nt m e thod ology. T he re fore , it is not s u rprisingthat the program s d e s igne d to im prove
qu ality ofs e rvic
e we re ine ffe c
tive .
A d d itionally, ou r m ortality re views id e ntified as u bs tantially high rate of oc
c
u rre nc
e of one or
m ore s e riou s laps e s in c
are d u ringthe c
ou rs e of the s e d e aths . U nfortu nate ly, the inte rnally
pe rform e d m ortality re views id e ntified none ofthe s e laps e s . Give n the inability ofthe e xisting
m ortality re view proc
e s s to ac
c
u rate ly id e ntify laps e s in c
are whic
hc
an the n be the bas is for
trainingand im ple m e ntation ofopportu nities for im prove m e nt, the s ys te m s hou ld c
ontrac
t with
44
ou ts ide c
ontrac
tors who have no pote ntialc
onflic
ts ofinte re s t who c
an m ore obje c
tive ly re view
the s e d e aths . T his is c
ons iste nt with an ove rall qu ality im prove m e nt program that has not
d e ve lope d the c
apac
ity to ide ntify proble m s and analyz e the c
au s e s and , bas e d on that analys is,
im ple m e nt im prove m e nt s trate gies . T he ove rallqu ality im prove m e nt program s at allins titu tions
ne e d to be re d e s igne d and re s tru c
tu re d in a m anne r that e ffe c
tive ly im prove s the qu ality of
s e rvic
es.
In the U nite d State s , bas e d on the d ire c
tion from the Joint C om m iss ion on A c
c
re d itation of
H e althc
are O rganizations , allhe althc
are program s , be the y hos pitals , c
linic
s , s u rgic
e nte rs , e tc
.,
are re qu ire d to be able to s e lf-m onitor and bas e d on that s e lf-m onitoringd e te rm ine whe the r
pe rform anc
e is ac
c
e ptable or not. W he n the pe rform anc
e is d e e m e d not ac
c
e ptable , the y are
e xpe c
te d to d eterm ine the c
au s e s or c
ontribu tingfac
tors to the u nac
c
e ptable pe rform anc
e and
the n the y are re qu ire d to im ple m e nt im prove m e nt s trate gies to ad d re s s the s e c
au s e s . Finally, the y
are re qu ire d to re as s e s s the pe rform anc
e afte r the im prove m e nt s trate gies have be e n
im ple m e nte d . W he n hos pitals , c
linic
s or s u rgic
e nte rs d o not have an e ffe c
tive qu ality
im prove m e nt program the y are not ac
c
re d ite d by the JC A H O and as are s u lt m ay los e the ability
to re c
e ive fe d e rald ollars . T he m os t im portant re as on why JC A H O has d e ve lope d this approac
h
ove r the las t 30 ye ars is to fac
ilitate a m ind s e t within he althc
are program s that foc
u s e s on
prote c
tingpatients s afe ty and the re by re d u c
ingavoidable harm to patients . T he s am e princ
iple s
m u s t apply to c
orre c
tional he althc
are s e rvic
e s and the c
re ation of an e ffe c
tive qu ality
im prove m e nt program at e ve ry s ite is the re fore c
ritic
alto provid ingad e qu ate c
are .
Recommendations:
1. A traine d Q u ality Im prove m e nt C oord inatorm u s t be as s igne d to e ac
hfac
ility.
2. T rainingform e m be rs ofthe line s taffs hou ld als o be provide d .
3. E ac
h fac
ility
s program s hou ld d e ve lop a c
ale nd ar in whic
h e ve ry m ajor s e rvic
e is
re viewe d at le as t onc
e aye ar.
4. W he n re views are pe rform e d , the y m u s t u tilize one or m ore of the e ight qu ality
pe rform anc
e m e as u re s .
5. E ac
hloc
alqu ality im prove m e nt program s hou ld be m e as u re d on the bas is ofthe e xte nt to
whic
hthe program fac
ilitate s im provingthe qu ality ofs e rvic
es.
6. T he State s hou ld c
ontrac
t with one or m ore e xte rnalqu ality re viewe rs for the m ortality
re view proc
e s s s inc
e the c
u rre nt proc
e s s was e xtre m e ly ine ffe c
tive at ide ntifying
s ignific
ant laps e s in c
are and the re fore ine ffe c
tive in he lpingim prove the qu ality of
s e rvic
e s provide d .
7. W he re the e xte rnalre views id e ntify one or m ore laps e s in c
are , the ins titu tion s hou ld be
re s pons ible ford e ve lopingac
orre c
tive ac
tion plan whic
his provide d to are gionalnu rs e
and the M e d ic
alD ire c
tor.
Conclusions
From the e ight s ite visits , the inte rviews with s taff and inm ate s , the re view of ins titu tional
d oc
u m e nts , the re view of m e d ic
alre c
ord s , inc
lu d ingd e ath re c
ord s and m ortality re views , we
have c
onc
lu d e d that the State of Illinois has be e n u nable to m e e t m inim al c
ons titu tional
s tand ard s with re gard s to the ad e qu ac
y of its he alth c
are program for the popu lation it s e rve s .
T his c
onc
lu s ion d oe s not im ply that the re are not m any d e d ic
ate d profe s s ionals workingwithin
45
the D e partm e nt ofC orre c

tions , as re c
ognize d and appre c
iate d by this te am . W he n im prove m e nts
are im ple m e nte d , the y willbe be tte rs itu ate d to ac
hieve the ou tc
om e s the y s trive for.
46
APPENDIX A
Stateville Correctional Center

(SCC) Report
February, 2014

Ron Shansky, MD
Karen Saylor, MD
Larry Hewitt, RN
Karl Meyer, DDS
Contents
Overview ................................................................................................................................... 3
Executive Summary .................................................................................................................. 3
Findings..................................................................................................................................... 5
Le ad e rs hipand Staffing..........................................................................................................5
C linicSpac
e and Sanitation....................................................................................................7
Intras ys te m T rans fe r...............................................................................................................8
N u rs ingSic
k C all...................................................................................................................9
P rovid e rSic
k C all................................................................................................................11
C hronicD ise as e M anage m e nt ..............................................................................................12
P harm ac
y/M e d ic
ation A d m inistration ..................................................................................20
Laboratory ...........................................................................................................................21
U rge nt/E m e rge nt C are ..........................................................................................................22
Sc
e s -C ons u ltations /P roc
e d u re s ..........................................................23
Infirm ary ..............................................................................................................................24
Infe c
tion C ontrol..................................................................................................................27
Inm ate s Inte rviews ..............................................................................................................28
D e ntalP rogram ....................................................................................................................29
C ontinu ou s Q u ality Im prove m e nt.........................................................................................37
Recommendations................................................................................................................... 38
Appendix A Patient ID Numbers ........................................................................................ 40
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 2
Overview
O n Janu ary 21-23, and Fe bru ary 24-25, 2014, we visite d the State ville C orre c
tionalC e nte rin Joliet,
Illinois. T his was the firs t s ite visit to SC C and this re port d e s c
ribe s ou r find ings and
re c
om m e nd ations . D u ringthis visit, we :
M e t withle ad e rs hipofc
u s tod y and m e d ic
al
T ou re d the m e d ic
als e rvic
e s are a
T alke d withhe althc
are s taff
R e viewe d he althre c
ord s and othe rd oc
u m e nts
Interviewe d inm ate s
W e thank W ard e n M ic
hae lM aganaand his s taffforthe iras s istanc
e and c
oope ration in c
ond u c
ting
the re view.
Executive Summary
State ville is am axim u m -s e c
u rity fac
ility. T he c
u rre nt popu lation forthe e ntire c
om ple x (N orthe rn
R ec
e ption C e nte r, M inim u m Se c
u rity U nit and State ville prope r)is 4078 inm ate s , approxim ate ly
1600 ofwhom we re hou s e d at State ville prope r, the foc
u s ofthis re port. T he m axim u m -s e c
u rity
u nit has a32-be d infirm ary whic
h s e rve s the e ntire c
om ple x. T he re are fou r d ialys is c
hairs at
State ville whic
hc
an the re fore ac
c
om m od ate u pto 18d ialys is patients .
T he re is am ajorproble m withac
c
e s s to c
are at this fac
ility. C linic
s are fre qu e ntly c
anc
e lle d d u e to
loc
kd owns , s taffingiss u e s , and to ale s s e rd e gre e by no s hows ,thu s re s u ltingin d e laye d orm iss e d
c
hronicc
are c
linic
s , te le m e d ic
ine visits and s ic
kc
all. In the c
harts that we re viewe d , anywhe re
from 33% to 75% ofs c
he d u le d appointm e nts we re c
anc
e lle d forthe s e re as ons .
T he M e d ic
alD ire c
tor is as u rge on by trainingand c
hart re views s u gge s te d that his prim ary c
are
s kills are not u pto d ate . T he othe r phys ic
ian has m ore c
u rre nt s kills , bu t ironic
ally d e fe rs to the
M e d ic
alD ire c
torforc
as e s whic
hare m ore c
om ple x orhighe rrisk. N e ithe rphys ic
ian has ac
c
e s s to
any e le c
tronicm e d ic
alre fe re nc
e s or re s ou rc
e s ;this d e c
re as e s the like lihood that patients willbe
tre ate d ac
c
ord ingto the m os t c
u rre nt ac
c
e pte d s tand ard s ofc
are . T his was ind e e d the c
as e in m any
ofthe c
harts we re viewe d .
A globalproble m withthe c
hronicc
are program is that patients are not s c
he d u le d ac
c
ord ingto the ir
d e gre e ofd ise as e c
ontrol, bu t rathe rby the c
ale nd arm onth. T his is astate wide polic
y iss u e which
ne e d s to be c
orre c
te d . W e als o fou nd m any ins tanc
e s in whic
hpatients c
hronicd ise as e s we re not
m anage d as aggre s s ive ly as the y s hou ld have be e n whe n the ird e gre e ofc
ontrolwas poor. In m any
ofthe c
harts that we re viewe d , the proble m lists we re not u pd ate d .
W ithre gard to the d iabe te s c
linic
, the tim ingbe twe e n ins u lin ad m inistration and the s tart ofthe
m e als c
an be qu ite variable , and fe e d ingtim e s c
hange d ay-to-d ay, plac
ingpatients at
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 3
c
ons id e rable risk ofhypoglyc
e m ia. P atients re qu iringins u lin are pre s c
ribe d this the rapy no m ore
than twic
e ad ay. W hile this m ay be s u ffic
ient for m any type 2 d iabe tic
s , phys iologicins u lin
re plac
e m e nt (with3-4inje c
tions pe rd ay)is re c
om m e nd e d forthe m ajority ofpatients withtype 1
d iabe te s .
W e note d ad istu rbingpatte rn oftre atm e nt inte rru ptions and d e lays in s pe c
ialty c
are for patients
withH IV infe c
tion. T e le m e d ic
ine c
linicvisits we re c
anc
e lle d and pos tpone d withs im ilarfre qu e ncy
as othe r c
hronicc
are c
linic
s d u e to loc
kd owns and s e c
u rity iss u e s . H owe ve r, c
om pou nd ingthe
proble m for the H IV patients is that the ons ite provide rs are alm os t c
om ple te ly u ninvolve d in
m anagingorm onitoringany as pe c
ts ofpatients H IV d ise as e . O ne ofthe c
ons e qu e nc
e s ofthis lac
k
of involve m e nt is that no one ons ite is m onitoringpatients m e d ic
ation ad he re nc
e . T hu s , whe n
patients ru n ou t ofm e d ic
ation ors kipd os e s , it appe ars that no one notic
e s u ntilthe patient
s ne xt
ID te le m e d ic
ine visit m any m onths late r. It is ofc
ru c
ialim portanc
e that patients not m iss d os e s or
ru n ou t ofH IV m e d s , as this is highly as s oc
iate d withtre atm e nt failu re and ad ve rs e ou tc
om e s .
A large part ofthe proble m is apolic
y iss u e . T he m os t re c
e nt c
opy ofthe D e partm e nt
s C hronic
Illne s s T re atm e nt Gu ide line s that we we re provid e d d id not e ve n c
ontain as e c
tion on H IV infe c
tion,
or d e fine an H IV c
hronicc
are c
linic
. Sim ilarly, the W e xford H IV polic
y ad d re s s e s e xpos u re
c
onc
e rns for e m ploye e s , bu t is e s s e ntially s ile nt on the iss u e ofH IV tre atm e nt for inm ate s . T he
fac
ility has thu s ad opte d aprac
tic
e ofle avingthe e ntire ty ofH IV c
are to the ID c
ons u ltant, ac
c
ess
to whom is qu ite lim ite d as alre ad y d isc
u s s e d . T his has had the u nfortu nate e ffe c
t ofe s s e ntially
d ise ngagingthe fac
ility provid e rs from any as pe c
t ofpatients H IV c
are . N one ofthe H IV patients
we re e nrolle d in the c
hronicd ise as e c
linicin the form alway that othe rpatients we re e nrolle d ;the y
we re s e e n by the ID s pe c
ialist only (and only whe n c
linic
s we re not c
anc
e lle d as d isc
u s s e d above ).
W hile we wou ld not e xpe c
t the ave rage prim ary c
are c
linic
ian to be fac
ile in tre atingH IV d ise as e
its e lf, we wou ld e xpe c
t the m to be provid ingprim ary c
are to this popu lation. T his wou ld inc
lu d e
ac
tive ly m onitoringthis high-risk popu lation for m e d ic
ation c
om plianc
e , s id e e ffe c
ts , and the
prim ary c
are c
om plic
ations re late d to the d ise as e and its tre atm e nt, s u c
has hype rlipid e m ia, d iabe te s
and c
ard iovas c
u lard ise as e .
P atients ad m itte d to the infirm ary at State ville we re ofte n not s e e n ac
c
ord ingto tim e line s d e s c
ribe d
by polic
y, e ithe rby the c
linic
ians orby the nu rs ings taff. W e we re als o s u rprise d to obs e rve s e ve ral
ins tanc
e s whe re patients c
ond itions we re not m anage d as aggre s s ive ly as the ir c
ond itions
warrante d d u ringthe irinfirm ary ad m iss ion.
State ville , give n the fac
t that it is am axim u m -s e c
u rity fac
ility and hou s e s m any old e r and s ic
ke r
patients , re qu ire s the s e rvic
e s of a H e alth C are U nit A d m inistrator d e d ic
ate d s pe c
ific
ally and
e xc
lu s ive ly to State ville . In ad d ition, the offic
ials taffingalloc
ation is inad e qu ate to m e e t the rathe r
d e m and ingm e d ic
al ne e d s . T he re s pons e has be e n to allow for the hiringof ad d itional s taff;
howe ve r, s u c
hac
om ple x fac
ility c
annot be allowe d to fu nc
tion on the bas is ofpos itions whic
hc
an
be d e le te d or d e laye d in te rm s ofhiringon am om e nt
s notic
e . T he State ville fac
ility re qu ire s a
d e s ignate d nu m be rofnu rs ingand prim ary c
are and m e d ic
alre c
ord s pos itions .
M os t ofthe s e rvic
e s at State ville are fre qu e ntly c
anc
e lle d , d u e to e ithe rloc
k d owns orno-s hows
orabs e nc
e ofhe althc
are s taff. T his re s u lts in s u bs tantiald e lays and s om e tim e s proble m s
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 4
not e ve rbe ingad d re s s e d . In ad d ition, the abs e nc

e ofle ad e rs hipand e s pe c
ially c
linic
alle ad e rs hip
re s u lts in prac
titione rpe rform anc
e whic
his fre qu e ntly ine ffe c
tive withno c
hanc
e ofim prove m e nt
be c
au s e ofthe abs e nc
e ofre view and fe e d bac
k.
T he intras ys te m trans fe rproc
e s s d oe s not e ffe c
tive ly ins u re c
ontinu ity ofc
are forpatients who e nte r
with prior d iagnos e d proble m s . In ad d ition, the u rge nt/e m e rge nt re s pons e s fre qu e ntly re fle c
t
proble m s with the initialas s e s s m e nt and re s pons e or with follow-u ps afte r patients retu rn from
s e nd ou ts. A d d itionally, s c
e s re fle c
t pe rs iste nt proble m s withthe tim e line s s of
ac
c
e s s to the s e s e rvic
e s orproble m s withfollow-u ponc
e the s e rvic
e is provide d . A nd finally, the
qu ality im prove m e nt program , whic
h s hou ld have ide ntified the program m aticd e fic
ienc
ies and
ad d re s s e d the m , is non-fu nc
tional, inc
lu d ingthe res pons e s to grievanc
es.
D u e to the m axim u m -s e c
u rity le ve lof inm ate s hou s e d in the fac
ility, it is only ne c
e s s ary and
appropriate that e xam room s be c
re ate d in c
e llhou s e s B , E and Fto allow s ic
kc
allto be c
ond u c
te d
in the c
e llhou s e , thu s re d u c
ingthe m ove m e nt of inm ate s ou t ofthe c
e llhou s e . In ad d ition, the
m e altim e s , withbre akfas t s tartingat 2:00a.m . and lu nc
hat 9:00a.m ., c
au s e re alproble m s forthe
d iabe tic
s to m aintain anorm ald iu rnalvariation withre gard to e atingand s le e ping. E ve ry e ffort
s hou ld be m ad e to m ove u pthe s tart ofthe m orningm e als to 3:30a.m . at the e arlies t.
Findings
Staffingis d iffic
u lt to as s e s s as are s u lt of State ville and the N orthe rn R e c
e ption C e nte r (N R C )
be ingviewe d as one fac
ility withone Sc
he d u le E ofapprove d and bu d ge te d s taffingpos itions . T his
m e ans the re is as haringofs taff, partic
u larly nu rs ings taff, who are m ove d bac
k and forthbe twe e n
the two fac
ilities d e pe nd ingon agive n ac
tivity or ne e d . For e xam ple , whe n the intake proc
ess
be gins at the N R C , nu rs ings taffat State ville go to the N R C to as s ist withintake . A s are s u lt, the
work be ingpe rform e d at State ville s tops and m ay not be re starte d d e pe nd ingon the nu m be r of
inm ate s goingthrou ghintake and the le ngthoftim e nu rs ings taffare re qu ire d to work at the N R C .
A d d itionally, whe n nu rs ings taff c
all-off work, s c
he d u le d s taff has to be m ove d arou nd to fill
thos e vac
anc
ies . Fore xam ple , ifanu rs e s c
he d u le d to work at the N R C d oe s not re port to work, a
nu rs e at State ville , who alre ad y has an as s ignm e nt, is pu lle d offthat as s ignm e nt and s e nt to the
N R C . D e pe nd ingon the d ay ofthe we e k and how m any nu rs ings taffare working, this c
ou ld re s u lt
in the d u ties the State ville nu rs e was originally as s igne d to pe rform not be ingd one . A re view of
s taffings c
he d u le s , c
all-offand ove rtim e re c
ord s s howe d ad aily oc
c
u rre nc
e ofnu rs inge m ploye e s
not re portingto work re s u ltingin s taffingad ju s tm e nts s hift by s hift. T he s c
he d u le s re viewe d
ind ic
ate d 100% ofthe tim e nu rs ings taffwas re m ove d from the iras s ignm e nt at State ville to filla
vac
anc
y/ne e d at the N R C . A s are s u lt, State ville is c
hronic
ally ou t ofc
om plianc
e withe s tablishe d
polic
y forthe tim e ly c
om ple tion ofs ic
kc
all, pe riod icphys ic
ale xam inations , c
hronicillne s s c
linic
s
and tim e ly ad m inistration ofm e d ic
ation. C om pou nd ingthis proble m is the s ignific
ant nu m be rof
s tate nu rs ingpos ition vac
anc
ies . For e xam ple , of20 approve d C orre c
tionalN u rs e II pos itions ,
10are u nfille d d u e to thre e vac
anc
ies and s e ve n long-te rm le ave s ofabs e nc
e . A ls o, of18approve d
C orre c
tionalM e d ic
alT e c
hnic
ian pos itions , e ight are u nfille d d u e to two vac
anc
ies , and again, s ix
long-te rm le ave s ofabs e nc
e . In
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 5
ord erto he lpc

om bat the s e s taffingproble m s , the c
ontrac
t m e d ic
alprovide rhas be e n au thorize d to
s u bm it A d ju s te d StaffingR e qu e s ts (A SR s ) to hire s taff ou ts ide of the au thorize d Sc
he d u le E
bu d ge te d pos itions . C u rre ntly, the c
ontrac
t m e d ic
al provide r has be e n au thorize d throu gh the
approvalof an A SR to hire atotalof 40 re giste re d nu rs e s (R N s ) and lic
e ns e d prac
tic
al nu rs e s
(LP N s ) ove r and above the bu d ge te d Sc
he d u le E pos itions . A t the tim e of the ins pe c
tion, a
c
om bination of27R N s and LP N s had be e n hire d .
W iththe view that State ville and the N R C fu nc
tion as one fac
ility, only one FT E H e althC are U nit
A d m inistrator(H C U A )is approve d to m anage the he althc
are program s at bothfac
ilities . D u e to
the s ignific
antly d iffe re nt m iss ions ofe ac
hfac
ility and the highle ve lofac
tivity at e ac
hfac
ility, it
is s trongly re c
om m e nd e d that the re is afu ll-tim e H e althC are U nit A d m inistratoras s igne d to e ac
h
fac
ility. C om pou nd ingthis iss u e is the fac
t that the c
u rre nt H C U A is c
hronic
ally abs e nt and take s
e xte nd e d Le ave s ofA bs e nc
e . A t the tim e ofthe ins pe c
tion, the H C U A was not available e xc
e pt for
approxim ate ly fou rhou rs one m orningat the N R C . T he m e e tinghad to oc
c
u rat the N R C be c
au s e
the H C U A was no longe rpe rm itte d by the ward e n to e nte rState ville as are s u lt ofale gbrac
e the
H C U A was re qu ire d to we ar. A s are s u lt, s he is u nable to provide any ad m inistrative ove rs ight or
m onitoringofthe he althc
are program or provide any gu id anc
e to s u pe rvisory or line s taff. T he
m e d ic
alc
ontrac
torD ire c
torofN u rs ingis m anagingthe he althc
are program and is qu ite c
om pe te nt.
O fad d itionalc
onc
e rn is the lac
k ofs trongle ad e rs hipat the N R , whic
hfu rthe rre inforc
e s the ne e d
for afu ll-tim e H C U A pos ition d e d ic
ate d to the N R C to provide d ire c
tion and ove rs ight of the
program .
T he u nd e rd e ve lopm e nt ofthe State ville he althc
are program is in part attribu table to aH e althC are
A d m inistratorpos ition whic
his fu nc
tionally vac
ant bu t is fille d by ape rs on on prolonge d m e d ic
al
le ave . T he M e d ic
alD ire c
torpos ition is fille d by as u rge on who d oe s not provide c
linic
alove rs ight
forthe program . T he re is afu nc
tioningD ire c
torofN u rs inge m ploye d by the ve nd orwho appe ars
to be workinghard to ke e pthe program afloat. T he le ad e rs hipvac
u u m , e s pe c
ially at s u c
hac
om ple x
fac
ility, is re s pons ible for the s tate ofprogram m aticu nd e rd e ve lopm e nt. T his vac
u u m appe ars to
have faile d to ide ntify or d e ve lop as trate gy that ad d re s s e s the ove rwhe lm ingac
c
e s s proble m s
re late d to loc
kd owns , e tc
.
O the rs taffingis liste d in the followingtable :
Table 1. Health Care Staffing
Position
M e d ic
alD ire c
tor
StaffP hys ic
ian
N u rs e P rac
titione r
H e althC are U nit A d m .
D ire c
torofN u rs ing
N u rs ingSu pe rvisor
C orre c
tions N u rs e I
C orre c
tions N u rs e II
Febru ary 2014
Current FTE
1.0
1.0
1.0
1.0
1.0
1.0
1.0
0
20.0
Filled
1.0
1.0
0
LO A
1.0
1.0
1.0
0
10.0
S tatevill
e C orrec ti
onalFac ili
ty
Vacant
0
0
LO A
LO A
0
0
0
0
3vac
.&
State/Cont.
C ontrac
t
C ontrac
t
C ontrac
t
State
C ontrac
t
State
C ontrac
t
State
State
P age 6
Position
Current FTE
Filled
R e giste re d N u rs e
Lic
e ns e d P rac
tic
alN u rs e s
C orre c
tionalM e d ic
alT e c
hnic
ian
0
7.0
18.0
0
7.0
10.0
H e althInform ation A d m .
H e althInfo. A s s oc
.
P hle botom ist
R ad iology T e c
hnic
ian
P harm ac
y Tec
hnic
ian
P harm ac
y Tec
hnic
ian
StaffA s s istant
StaffA s s istant
1.0
2.0
0.5
0
0
1.0
1.0
2.0
1.0
2.0
0.5
0
0
1.0
1.0
0
C hiefD e ntist
D e ntist
D e ntalH ygienist
D e ntalA s s istant
O ptom e try
P hys ic
alT he rapist
P hys ic
alT he rapy A s s t.
Total
1.0
2.0
1.0
2.0
0.2
0.4
0
66.1
1.0
2.0
1.0
1.0
0.2
0.4
0
43.1
Vacant State/Cont.
7LO A
0
C ontrac
t
0
C ontrac
t
2vac
.&
State
6LO A
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
State
0
C ontrac
t
1vac
.&
C ontrac
t
1, 13yr.
LO A
0
C ontrac
t
0
State
0
C ontrac
t
1
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
23 (19
state & 4
contract)

T he State ville he alth c
are u nit was c
le an, we ll lighte d , re as onably we ll m aintaine d and
e nvironm e ntally c
om fortable . It is alarge u nitc
ons istingoffou rlarge inm ate hold ing/waitingare as ,
an u rge nt c
are /e m e rge nc
y room , m e d ic
ation pre paration room , m e d ic
ation s torage , m e d ic
als u pply
and s torage , m e d ic
alre c
ord s d e partm e nt, fou r-c
haird e ntalc
linic
, a32-be d infirm ary and m u ltiple
offic
e are as .
Inm ate porte rs perform the janitoriald u ties .
T he u rge nt c
are /e m e rge nc
y room was appropriate ly e qu ippe d . A rand om ins pe c
tion ofc
ontrolle d
m e d ic
ation, ne e d le s /s yringe s , s harpins tru m e nts and tools ind ic
ate d allpe rpe tu alinve ntories we re
ac
c
u rate and be ingc
ou nte d at the appropriate inte rvals . K e ys to ac
c
e s s the pre viou s ly m e ntione d
ite m s we re appropriate ly re s tric
te d to on-d u ty m e d ic
als taff. A n au tom atice xte rnald e fibrillator
(A E D )and e m e rge nc
y re s pons e kit are c
he c
ke d e ac
hs hift to as s u re ope rability ofthe A E D and
ad e qu ate and appropriate e m e rge nc
y s u pplies . T he d e ntalc
linicwas ve ry c
le an, we llm aintaine d
and organize d . T he m e d ic
alre c
ord s d e partm e nt was le s s organize d and
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 7
c
lu tte re d . T he m e d ic
ation pre paration and s torage room s we re c
le an, organize d and appropriate ly
e qu ippe d withac
c
e s s re s tric
te d to m e d ic
alpe rs onne l.
T he infirm ary is alarge re c
tangle , two longhallways and two s hort hallways , withanu rs ings tation
c
e ntrally loc
ate d in the m id d le ofthe re c
tangle .
B lood -borne pathoge n pre c
au tions we re be ingu s e d in allare as as e vid e nc
e d by the u s e ofs harps
c
ontaine rs , pe rs onal prote c
tive e qu ipm e nt available for u s e as ind ic
ate d , the u s e of a lic
e ns e d
m e d ic
al was te d ispos al c
om pany, the ID O C blood -borne pathoge n m anu al be ingim m e d iate ly
available to s taffand s tafftrainingon the s u bje c
t m atte r.
In this are awe look at how we llthe fac
ility proc
e s s e s ne wly e nte ringinm ate s in ord e rto ins u re
c
ontinu ity ofc
are . W e re viewe d 13re c
ord s ofwhic
hs e ve n had s ignific
ant proble m s .
Patient #1
T his is a45-ye ar-old m ale withhe patitis C who arrive d at State ville on 1/2/14. T his patient had
c
om ple te d tre atm e nt forhe patitis C and ye t the trans fe rs u m m ary lac
ks ad e s c
ription ofthis prior
tre atm e nt.
Patient #2
T his is a45-ye ar-old withhe aringlos s who arrive d on 1/28/14. A gain, the trans fe rs u m m ary lac
ks
any d oc
u m e ntation ofthe s ignific
ant he aringlos s .
Patient #3
T his is a38-ye ar-old who arrive d on 1/24/14. T his patient, on arrival, had an e le vate d s ys tolic
pre s s u re bu t was ne ve rre fe rre d e ithe rform onitoringorc
linician visit.
Patient #4
T his is a26-ye ar-old withm e ntalhe althiss u e s and polys u bs tanc
e abu s e who arrive d on 1/2/14. In
this re c
ord , the R N wrote on the trans fe r form , vitals igns not ind ic
ate d . V itals igns s hou ld be
e xpe c
te d withou t e xc
e ption on allintras ys te m trans fe rs .
Patient #5
T his patient arrive d on 1/9/14, bu t the form s are blank.
Patient #6
T his is a29-ye ar-old who arrive d on 1/15/14withahistory ofas thm aand ps yc
hiatricproble m s . H e
was liste d as his as thm abe ingin good c
ontrolwithou t m e d s bu t the re was no c
hronicc
are re fe rral
and no e valu ation by aphys ic
ian to d ete rm ine whe the rthe as thm as hou ld be d e s c
ribe d as re s olve d
and the re fore not in ne e d ofany follow u p.
Patient #7
T his is a53-ye ar-old m ale withhype rte ns ion and c
atarac
ts who arrive d on 1/2/14. H owe ve r, the re
is no trans fe rs u m m ary available in his re c
ord .
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 8
Nursing Sick Call

State ville u s e s as ic
kc
allre qu e s t s ys te m fornu rs ings ic
kc
all. Inm ate s wantingto ac
c
e s s s ic
kc
all
c
om ple te as ic
kc
allre qu e s t form that is available in the c
e llhou s e s . O nc
e c
om ple te d , the inm ate
d e pos its the form d ire c
tly into aloc
ke d m e d ic
ald rop-box whic
his loc
ate d in e ac
hc
e llhou s e . E ac
h
m orningon the 7:00a.m . to 3:00p.m . s hift, ac
orre c
tionalm e d ic
alte c
hnic
ian (C M T )who c
ou ld be
alic
e ns e d prac
tic
alnu rs e (LP N )oranon-lic
e ns e d s taffm e m be r, c
olle c
ts and re views e ac
hs lipto
d e te rm ine whic
hinm ate s ne e d to be e valu ate d im m e d iate ly ve rs u s thos e who c
an be s c
he d u le d ove r
the ne xt 72hou rs . T he C M T d oc
u m e nts in as ic
kc
alllogbook e ac
hinm ate
s nam e , nu m be r, d ate
ofre qu e s t, d ate re viewe d , d ate s c
he d u le d and the d ate to be e valu ate d . Inm ate s d ete rm ine d to ne e d
u rge nt c
are are re fe rre d to e ithe rare giste re d nu rs e (R N )orphys ic
ian and e valu ate d the s am e d ay.
Inm ate s d e te rm ine d to not have an im m e d iate ne e d are s c
he d u le d to be e valu ate d within 72hou rs .
R e giste re d nu rs e s (R N s ) c
ond u c
t s ic
k c
all. Sic
k c
all in F-hou s e , whic
h is ad m inistrative and
d isc
iplinary s e gre gation, is c
ond u c
te d thre e tim e s awe e k, and s ic
kc
allin c
e llhou s e s B , C , D , E
and X are c
ond u c
te d two tim e s awe e k. Sic
kc
allis c
ond u c
te d in e ac
hc
e llhou s e . A room has be e n
d e s ignate d on the bottom floorofe ac
hc
e llhou s e fors ic
kc
all;howe ve r, the room s in c
e llhou s e s
B , E and Fd o not have an e xam ination table . Se c
u rity s taffe s c
orts e ac
h inm ate to the s ic
kc
all
room . T he R N e valu ate s the inm ate and e ithe r tre ats the ind ivid u al from aphys ic
ian approve d
tre atm e nt protoc
ol or re fe rs the ind ivid u al to the phys ic
ian. D e partm e nt of C orre c
tions policy
re qu ire s re qu e s t s lips are re viewe d within 24hou rs ofre c
e ipt, and thos e ind ivid u als d e te rm ine d to
have rou tine re qu e s ts are s c
he d u le d and e valu ate d within 72hou rs ofre qu e s t s lipre view. P e rthe
D ire c
torofN u rs ing(D O N ), ind ivid u als withrou tine he althc
are re qu e s ts are e valu ate d within five
d ays rathe rthan the re qu ire d thre e d ays .
It was re porte d that nu rs ings ic
kc
allis fre qu e ntly inte rru pte d orterm inate d be c
au s e s e c
u rity s taff
willm ake the d e c
ision to no longe r e s c
ort inm ate s from the galle ries d own to the nu rs e s ic
kc
all
room on the firs t floor.
T e n nu rs e s ic
kc
allre c
ord s we re re viewe d as follows .
Patient #1
T his patient is a55-ye ar-old . H e s u bm itte d are qu e s t s lipd ate d 11/15/2013c
om plainingofs e ve re
abd om inalpain withblood in s tool;it was note d as re c
e ive d on 11/23. T he re qu e s t was re viewe d
by aC M T and s c
he d u le d for 11/25. H e was e valu ate d by aR N 11/29. T he SO A P note s tate d ,
P atient c
om plaine d ofs tabbingpain in abd om e n and blood in s toolforpas t s ix m onths .T he R N
note d no re bou nd orte nd e rne s s and bowe ls ou nd s in allfou rqu ad rants . T he d oc
u m e nte d plan was
to avoid fatty food s and he was re fe rre d to the phys ician on 12/18. H e was e valu ate d in
c
ard iac
/hype rte ns ion c
linicon 12/10, bu t abd om inalpain and blood in s toolwe re not ad d re s s e d .
H e was not e valu ate d by phys ician on 12/18d u e to no provid e rand was re s c
he d u le d for1/9/2014.
H e was not e valu ate d by phys ician on 1/9d u e to no provid e rand the re we re no fu rthe rnote s .
T his patient had the s am e c
om plaints in A u gu s t 2013, and afte r s u bm ittingfive re qu e s ts , he was
e valu ate d by the phys ic
ian
s as s istant on 8/5/2013. T he re is ad oc
u m e nte d e xam notingblood on
e xam glove afte rre c
tale xam and palpable inte rnalhe m orrhoid s . T he as s e s s m e nt was c
ons tipation,
analfiss u re and he m orrhoid s . Fibe rLax and A nnu s ol-H C s u ppos itories we re ord e re d . T he patient
s
m e d ic
alre c
ord re fle c
ts that he was not e valu ate d in s ic
kc
allas s c
he d u le d on 8/19, 8/21, 8/28, 8/30,
9/9, 9/13and 9/26/13d u e to loc
kd own.
Patient #2
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P Page
age10
9
T his is a58-ye ar-old patient with d iabe te s and hype rte ns ion. H e was e valu ate d on 12/23/13 in
u rge nt c
are forc
om plaints ofs toppingbre athingwhe n as le e p, whic
hwake s him withs hortne s s of
bre ath. V itals igns we re c
olle c
te d and re c
ord e d ;blood pre s s u re was e le vate d at 148/98. T he re was
no d oc
u m e nte d as s e s s m e nt orplan and he was ins tru c
te d to retu rn as ne e d e d . O n 1/18/14at 2:45
a.m ., he re porte d to u rge nt c
are with c
om plaints of c
he s t pain. V ital s igns we re c
olle c
te d and
d oc
u m e nte d and allwe re W N L. T he phys ic
ian was notified and an E K G ord e re d . T he E K G was
pe rform e d and re porte d to the phys ic
ian, who ord e re d pain m e d ic
ation and N itro 0.4m g. SL and
re port bac
k to phys ic
ian in 30m inu te s . T he phys ic
ian was c
ontac
te d afte r30m inu te s and told that
the patient re porte d he no longe rhad any pain. T he patient retu rne d to the c
e llhou s e . A t ac
ard iac
c
linicappointm e nt on 1/21, the patient re porte d he no longe r was havingc
he s t pain, bu t he
fre qu e ntly wake s u pnot bre athing. T his was not ad d re s s e d in c
ard iacc
linic
.
Patient #3
T his patient is a49-ye ar-old . H e s u bm itte d are qu e s t s lipwhic
hwas note d as re c
e ive d and triage d
on 11/21/13by aR N . H e was e valu ate d by an R N on 11/25 forac
om plaint ofs harppain in his
right ribc
age are as inc
e playinghand ballawe e k pre viou s ly. V itals igns we re note d and allW N L.
T he patient rate d his pain as 7 ou t of10. N o e xam ination was note d . A c
e tam inophe n two tabs
T ID fors e ve n d ays we re give n and he was told to re tu rn as ne e d e d . T he re we re no fu rthe rnote s .
Patient #4
T his patient is a37-ye ar-old . T he re is no d oc
u m e ntation as to the d ate the re qu e s t was re c
e ive d and
triage d . H e was s c
he d u le d to be e valu ate d 12/20/13forc
om plaint ofs tom ac
hpain. H e was note d
as ano-s how and re s c
he d u le d for 12/27. H e was e valu ate d on 12/27 with ac
om plaint of R LQ
inte rm itte nt pain, no N /V ord iarrhe aand vitals igns W N L. A n abd om inale xam ination note d with
bowe ls ou nd s x 4and R LQ protru s ion whe n patient c
ou ghs . T he as s e s s m e nt was he rniaand he was
re fe rre d to the phys ic
ian. H e was s c
he d u le d for 1/8/14, bu t not e valu ate d d u e to no provide r. H e
was re s c
he d u le d for1/21, bu t note d as ano-s how. H e was re s c
he d u le d for2/4, bu t the re we re no
fu rthe rnote s .
Patient #5
T his patient is a37-ye ar-old . T he re was are qu e s t note d as re c
e ive d and triage d 11/17/13by aR N .
H e was s c
he d u le d for s ic
kc
all11/20 for c
om plaint ofU R I. H e was s e e n 11/20, bu t s tate d he no
longe rhad any c
om plaints and he was ins tru c
te d to retu rn as ne e d e d .
Patient #6
T his patient is a47-ye ar-old . T he re was are qu e s t note d as re c
e ive d and triage d 11/22/13by aR N .
T he re was are qu e s t to have ac
olonos c
opy and it was s c
he d u le d for11/30. H e was not s e e n 11/30
d u e to no provide rand was re s c
he d u le d for12/7. H e was not s e e n on 12/7d u e to no provide rand
re s c
he d u le d for12/11. A gain, he was not s e e n 12/11d u e to tim e c
ons traints ,and re s c
he d u le d for
12/14. H e was e valu ate d by aR N on 12/14 and re fe rre d to phys ic
ian on 12/23 to d isc
u s s the
proc
e d u re. H e was not s e e n 12/23d u e to no provid e rand the re we re no fu rthe rnote s .
Patient #7
T his patient is a51-ye ar-old . A re qu e s t was note d as re c

e ive d and triage d 1/15/14 by aR N . H e
c
om plaine d ofabd om inalpain and was s c
he d u le d for1/18. H e was pre viou s ly e valu ate d on 1/2for
ac
om pliant of c
ons tipation;C olac
e and Fibe r Lax we re ord e re d . O n 1/10, he c
om plaine d of
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 11
abd om inalpain and was e valu ate d by aphys ic

ian in u rge nt c
are . A n abd om inale xam was note d as
W N L. H . pyloritre atm e nt was s tarte d and follow-u ps c
he d u le d for1/20. H e was not s e e n on 1/20
d u e to no provid e rand was re s c
he d u le d for1/22. H e was s e e n by an LP N and re s c
he d u le d withthe
phys ic
ian for2/19. T he re we re no fu rthe rnote s .
Patient #8
T his patient is a32-ye ar-old . H e s u bm itte d are qu e s t s lipc
om plainingofte s tic
u larpain;the re was
no d ate on the s lipand no d ate as to whe n the s lipwas re c
e ive d and triage d . H e was s c
he d u le d for
s ic
kc
allfor1/22/14. H e was s e e n by an R N and the re was no d oc
u m e nte d e xam ination. H e was
re fe rre d to aphys ic
ian. H e was e valu ate d by aphys ician on 1/23 and s tarte d on antibiotic
s. H e
was s c
he d u le d forfollow-u pon 2/19.
Patient #9
T his patient is a32-ye ar-old . H e s u bm itte d are qu e s t s lipc
om plainingofwe akne s s and we ight los s ;
the re qu e s t was d ate d as re c
e ive d and triage d 12/24/13. H e was s c
he d u le d fors ic
kc
allon 12/26.
H e was e valu ate d by an R N and s c
he d u le d for ac
hronicc
are c
linic
. T he re was no d oc
u m e nte d
e xam ination, as s e s s m e nt orplan and no d oc
u m e ntation ad d re s s ingwe akne s s and we ight los s .
Patient #10
T his patient is a37-ye ar-old . H e s u bm itte d are qu e s t c
om plainingofad isloc
ate d thu m b;the re qu e s t
was d ate d as re c
e ive d and triage d on 12/28/13. H e was s c
he d u le d fors ic
kc
all1/3/14. O n 1/3, the
patient was e s c
orte d to the he althc
are u nit and e valu ate d by an R N . A pre printe d s ic
kc
allprotoc
ol
form was c
om ple te d bu t not d ate ortim e s tam pe d . T he patient was re fe rre d d ire c
tly to the phys ic
ian.
T he phys ic
ian ord e re d s tatlabwork d u e to pos s ible alte re d m e ntals tatu s , and x-ray ofthe le ft
thu m b. T he re was no d oc
u m e ntation in the re c
ord ofan x-ray be ingpe rform e d orany re s u lts . T he
note from the phys ic
ian, whic
hhad no d ate ortim e , state d that the patient was inform e d he had a
s traine d thu m bwhic
hhad he ale d . T he re was no fu rthe rd oc
u m e ntation.
Provider Sick Call

W e re viewe d nine re c
ord s ofpatients s e e n in P A s ic
kc
alland s ix ofthe re c
ord s c
ontaine d s om e
proble m s .
Patient #1
T his is a31-ye ar-old m ale who on 11/18/13 was re fe rre d for pain at the bas e of his ne c
k. T he
as s e s s m e nt was appropriate bu t the re is no u s e ofapain s c
ale in ord e rto qu antify the s e ve rity of
the pain. N e c
k film s we re ord e re d alongwith s ym ptom atictre atm e nt. T he ne c
k x-rays we re
ne gative and he was to be followe d u p in thre e we e ks , bu t no visit oc
c
u rre d u ntilm ore than two
m onths late r, at whic
htim e ne w tre atm e nt ord e rs we re iss u e d .
Patient #2
T his is a35-ye ar-old withhype rte ns ion and obe s ity s e e n on 11/18/13forbu m ps on the bac
k ofhis
he ad and als o forre ne walofblood pre s s u re m e d ic
ine s . H e was as s e s s e d as havingfollic
u litis and
the m e d s we re re ord e re d bu t not u ntilnine d ays late r.
Patient #3
T his is a35-ye ar-old who was s e e n on 11/18/13forbac
k pain. H e had be e n s e e n fou rd ays e arlier
by the M e d ic
alD ire c
torbu t bac
k pain was not ad d re s s e d . O n 11/18the C M T wrote , N o ne e d to
be s e e n be c
au s e the patient had be e n s e e n by the phys ic
ian fou rd ays e arlierforthe s am e proble m .
T his was inac
c
u rate . O n 1/2/14, he was s c
he d u le d to s e e the phys ic
ian bu t the re c
ord ind ic
ate s N o
provide rpre s e nt.A gain, on 2/1the visit was c
anc
e lle d d u e to inad e qu ate staffingforR N s ic
kc
all.
T his patient has not be e n s e e n s inc
e the s e u nre s olve d c
om plaints .
Patient #4
T his is a49-ye ar-old withahistory ofafu ngalinfe c
tion ofhis toe nails as we llas proptos is. H e was
to be s e e n on 11/19/13 for follow u p oflaboratory te s ts bu t was not s e e n u ntil12/16. T re atm e nt
was ord e re d in the progre s s note bu t we we re u nable to find the pre s c
ription. T he re was als o a
re qu e s t forfollow u pin one m onthbu t this als o ne ve rtook plac
e.
Patient #5
T his is a 57-ye ar-old with as thm a and hype rlipid e m ia s e e n 11/21/13 for inc
re as e d u rination.
Laboratory te s ts we re ord e re d bu t ne ve rpe rform e d and the re fore the re was no follow u p.
Patient #6
T his is a55-ye ar-old who was s e e n on 11/21/13 for prostate proble m s . T he patient has be e n on
Flom ax and he was to re c
ord the fre qu e nc
y ofhis s ym ptom s and to retu rn in 7-10 d ays . H e was
ne ve r s e e n in follow u p bu t was s e e n 12/13 in his s c
he d u le d hype rte ns ion c
linic
, bu t the u rinary
proble m s we re ne ve rad d re s s e d .

T he re are two d e d ic
ate d c
hronicd ise as e nu rs e s ;one forthe highriskc
linic
s (H IV , he patitis C ,
ge ne ralm e d ic
ine )and one forthe m ore rou tine d ise as e s (hype rte ns ion, d iabe te s , as thm a, s e izu re ).
Like wise , the d oc
tors c
hronicc
are re s pons ibilities are d ivid e d alongthe s am e line s . P atients are
s e e n e ve ry fou rm onths re gard le s s ofd e gre e ofc
ontrol, thou ghD r. D willofte n re qu e s t follow-u p
visits in the inte rim . U nfortu nate ly, the s e inte rim visits are fre qu e ntly thrown offby loc
kd owns and
ins tanc
e s ofno provide r. Labs are re liably d rawn tim e ly be fore the c
hronicc
are appointm e nts
and allc
hronicd ise as e s are ad d re s s e d at e ac
hc
hronicc
are c
linicvisit, thou ghthis ofte n re qu ire s
the provide rto fillou t m u ltiple form s foras ingle visit. P roble m lists we re fre qu e ntly not u pto d ate
and we note d m u ltiple ins tanc
e s ofpatients ru nningou t ofthe irm e d ic
ations .
Cardiac/Hypertension
Patient #1
T his is a54-ye ar-old withd iabe te s , hype rlipid e m iaand c
oronary arte ry d ise as e . H is proble m list
was las t u pd ate d in 1999and d oe s not list c
oronary arte ry d ise as e . T he patient had an M I in 2007
withs te nt plac
e m e nt, the n anothe rs te nt in 2008. H e was s e e n in hype rte ns ion c
linicon 5/24/13
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 12
c
om plainingofc
he s t pain, s tating, It fe e ls like m y he art pain.T he phys ic
ian note d the patient
s
history ofc
oronary arte ry d ise as e bu t d id not get an E C G. Ins te ad , the plan was to re fe rto M e d ic
al
D ire c
torc
linicforfu rthe re valu ation ofthe c
he s t pain and s u blingu alnitroglyc
e rin was ord e re d as
ne e d e d . She als o note d that the patient
s hype rlipid e m iawas u nd e rpoorc
ontrolbu t m ad e no c
hange
to his m e d ic
ations .
She d id re fe r the patient for ingrown toe nailre m ovaland s aw him bac
k forthis on two d iffe re nt
oc
c
as ions .
T he ne xt note is d ate d 6/20, whe n the patient s aw the M e d ic
alD ire c
torford ys pne aon e xe rtion and
e xe rtionalc
he s t pain as in 2007and 2008whe n he had c
ard iacs te nting.H e ord e re d ac
he s t x-ray
and E C G this we e k and re fe rre d the patient to c
ard iology. T his was approve d on 6/24, bu t not
sc
he d u le d u ntil12/10, ne arly s ix m onths late r.1 T he x-ray was s c
he d u le d for6/26, bu t not d one d u e
to loc
kd own. It was re s c
he d u le d for6/28, bu t again c
anc
e lle d d u e to loc
kd own. It was finally d one
on 7/10, thre e we e ks afte rit was ord e re d .
H is ne xt c
hronicc
are visit was not u ntil9/27, at whic
htim e he d e nied c
he s t pain or s hortne s s of
bre athbu t was havingpalpitations . H is LD L was s tillabove goalat 129, so the phys ic
ian s toppe d
his s im vas tatin 20 m gand starte d pravas tatin 40 m g(ahighe r d os e of ale s s pote nt d ru gwhic
h
e s s e ntially am ou nts to no c
hange ). She als o ord e red naproxe n 500m gtwic
e ad ay rou tine ly fors ix
m onths , whic
h is re lative ly c
ontraind ic
ate d in patients with c
oronary artery d ise as e . She note d
follow u pwithc
ard iology as s c
he d u le d ,im plyinge ithe rthat the s ix-m onthd e lay was ac
c
e ptable
to he ror s he was not aware ofthe s c
he d u le d appointm e nt d ate . T he re are no fu rthe rc
hronicc
are
note s , thou ghhe was s e e n afe w tim e s fore ye c
om plaints and s hou ld e rpain.
H e the n pre s u m ably we nt to his c
ard iology appointm e nt on 12/10and e nd e d u pbe ingad m itte d to
the hos pital, as the ne xt note s in the c
hart s tate that he was retu rningto the ins titu tion having
u nd e rgone triple bypas s s u rge ry. H e was ad m itte d to the infirm ary. T he re we re no hos pitalnote s or
note s from the c
ard iology appointm e nt.
Opinion:T his patient pre s e nte d with c
he s t pain that s e e m e d c
le arly anginal in natu re ;he e ve n
d esc
ribe d it as id e ntic
alto his known c
ard iacc
he s t pain. T he firs t d oc
tord id nothingto work this
u p as ide from re fe r the patient to he r c
olle agu e , who is no m ore ad e pt than s he is. T he M e d ic
al
D ire c
torals o took ave ry c
as u alapproac
hto the proble m , e vid e ntly tole ratingas ix-m onthd e lay in
s pe c
ialty c
are forthis pote ntially life -thre ate ningproble m .
Patient #2
T his is a55-ye ar-old m an withhype rte ns ion, d iabe te s , hype rlipid e m ia, c
oronary arte ry d ise as e and
H IV , bu t his proble m list m e ntions only d iabe te s and hype rte ns ion.
We spoke to the scheduler about this excessive delay, who explained that UIC only allows a limited number of appointment
slots for all prison referrals. She submits the list of patients who are approved for consultation to UIC and is later informed of
the appointment information. She stated that if the provider wants the patients to be seen sooner, they can request that she
arrange for the patient to see a local provider. However, there is no system in place to inform the providers of when the UIC
appointment is going to occur.
1
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 13
A t the 4/13/13c
hronicc
are c
linichis blood pre s s u re was 140/103, bu t the patient had not had his
m e d s that m orning;the re was no fu rthe re xploration ofthis iss u e . T he d oc
torord ere d blood pre s s u re
c
he c
ks and e nc
ou rage d c
om plianc
e . She ord e re d afollow-u pvisit in two we e ks . H e was s c
he d u le d
on 5/4and 5/8, bu t not s e e n d u e to loc
kd owns .
O n 5/17, he was s e e n in c
hronicc
are c
linic
, at whic
h tim e his blood pre s s u re was 130/92 and
lisinoprilwas ad d e d . H is blood pre s s u re re m aine d e le vate d afte r that:139/98, 130/94, 138/97,
142/84, 146/110, bu t he was not s e e n again by aprovide r u ntilhis ne xt c
hronicc
are c
linicfive
m onths late r, on 10/15. A t this visit, his blood pre s s u re was 140/90and again he had not take n his
m e d s that d ay. T he d oc
torord e re d blood pre s s u re c
he c
ks we e kly fors ix m onths bu t d id not c
hange
his m e d ic
ation.
O n 1/9/14, he was s e e n forare s piratory illne s s and his blood pre s s u re was 130/94, whic
hwas not
ad d re s s e d .
H e was s c
he d u le d forc
hronicc
are c
linicon 1/17/14, bu t not s e e n d u e to no s how.
O n 1/21and 1/30, he was s e e n by the M e d ic
alD ire c
torforongoingre s piratory s ym ptom s and his
blood pre s s u re at bothvisits was e le vate d (128/91and 145/101)bu t not ad d re s s e d .
O n 1/30, the d oc
torre viewe d his labs and re qu e s te d afollow-u pvisit. H e was s c
he d u le d for2/1,
bu t he was not s e e n d u e to m inim alm ove m e nt pe r s hift c
om m and e r. H e was re s c
he d u le d for
2/22, bu t not s e e n d u e to no provide r.
Opinion:T his patient has not be e n s e e n tim e ly for his inad e qu ate ly c
ontrolle d hype rte ns ion, nor
has this proble m be e n ad d re s s e d withany vigor. The re s hou ld be no s u c
hthingas ano s howin
am axim u m -s e c
u rity prison.
Diabetes
B re akfas t is s e rve d d u ringwhat m os t pe ople wou ld c
ons id e rthe m id d le ofthe night, 1:30a.m . to
3:30 a.m . D iabe tic
s ge t as nac
k bagat bre akfas t. A nu rs e is s e nt to the u nit and waits u ntilthe
food is the re be fore ad m iniste ringthe ins u lin. Lu nc
his be twe e n 8:45a.m . and 12:40p.m . and is
s e rve d in the d ininghall. D inne rm ay be s e rve d any tim e be twe e n 4:30p.m . and 7:30p.m . P atients
on ins u lin ge t anothe rs nac
k bagat 3:00p.m . Ins u lin line s are ru n at the he althc
are u nit priorto
d inne r;patients re tu rn to the irc
e lls u ntilthe irtier is c
alle d . T he wait tim e s be twe e n the ins u lin
ad m inistration and the be ginningofthe m e althe re fore c
an be qu ite variable . W e we re told that
the fe e d ingord e r c
hange s d aily d u e to s e c
u rity c
onc
e rns . T he re are two ins u lin ad m inistration
tim e s ad ay;none ofthe d iabe tic
s we re ord e re d ins u lin m ore fre qu e ntly than twic
e ad ay.
W e fou nd proble m s in the followingc
as e s :
Patient #3
oronary arte ry d ise as e . H e was s e e n in
c
hronicc
are c
linicon 5/24/13withd iabe te s c
ontrolthat had be e n d e te rioratingove rthe pas t
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 14
ye ar. H is A 1chad grad u ally rise n from 9.2% in A u gu s t 2011to the m os t re c

e nt valu e of12.3% on
5/17/13, ye t the provid e rm ad e no c
hange s to his ins u lin d os e .
H is ne xt c
hronicc
are visit was on 9/27, at whic
htim e his A 1cwas 9.8% . H is bas alins u lin d os e
was inc
re as e d from 70to 74u nits at be d tim e and s lid ings c
ale ins u lin was ad d e d . Follow u pwas
ord ere d for11/7withanothe rA 1cprior;howe ve r, he was not s e e n that d ay d u e to loc
kd own. H e
was re s c
he d u le d for 11/9, bu t not s e e n that d ay d u e to no provide r. O n 11/19, the re is anothe r
note ind ic
atingthat he was not s e e n d u e to no provide r. W he n he was finally s e e n on 11/26, it
was to ad d re s s an e ye c
om plaint, not his d iabe te s .
Opinion:T his patient has not be e n s e e n tim e ly forhis d iabe te s and his d ise as e has not be e n m anage d
as aggre s s ive ly as his poorc
ontrolwarrants .
Patient #4
T his is a 61-ye ar-old d iabe ticwith hype rte ns ion, hype rlipid e m ia, hypothyroid ism and c
olon
c
anc
e r. H is proble m list was las t u pd ate d on 11/22/12 and d oe s not list hype rlipid e m ia or
hypothyroid ism . H is d iabe te s c
ontrolhas be e n im provingove rthe pas t ye arand is now u nd e rgood
c
ontrol. H is c
hronicc
are c
linic
s have not always oc
c
u rre d tim e ly ove rthe pas t ye ar, thou ghhe has
be e n s e e n forhis c
hronicd ise as e s fou rtim e s s inc
e Fe bru ary 2013and is u nd e rgood c
ontrolnow.
H is c
anc
e rc
are follow u phas not be e n tim e ly ac
c
ord ingto his m os t re c
e nt onc
ology re port, whic
h
d esc
ribe s the patient be inglos t to follow u pon two oc
c
as ions , whic
hre s u lte d in d e lays in work
u pand tre atm e nt.
Opinion:T his patient has not be e n s e e n tim e ly forhis c
anc
e rc
are , whic
hhas ne gative ly im pac
te d
the tim e line s s ofhis tre atm e nt. H is proble m list ne e d s to be u pd ate d .
Patient #5
T his is a58-ye ar-old m an withd iabe te s , hype rte ns ion and as thm a. H is d iabe te s has be e n poorly
c
ontrolle d ove r the pas t ye ar. A t the 1/18/13 visit, his A 1cwas 10.7% and his m e tform in was
inc
re as e d . H e was s c
he d u le d to be s e e n by the M e d ic
alD ire c
toron 1/29, 2/6, and 3/21, bu t was not
s e e n on any ofthe s e d ate s d u e to no provide r.O n 5/7, he was s c
he d u le d to be s e e n bu t was not
d u e to aloc
k d own. H e was ne xt s e e n on 5/30 in c
hronicc
are c
linic
, at whic
htim e his A 1chad
im prove d to 8.4% , bu t his m e tform in was d isc
ontinu e d d u e to re nalins u ffic
ienc
y. T he re was no
plan to m onitor the e ffe c
t of this inte rve ntion as id e from followingu p rou tine ly in c
hronicc
are
c
linicin fou rm onths .
O n 7/24, his A 1cwas m e as u re d at 11.1% . T his was re viewe d by the d oc
toron 8/1, who ord e re d
afollow-u pappointm e nt for8/8, bu t patient was not s e e n d u e to loc
kd own. H e was s e e n on 8/14,
at whic
h tim e the d oc
tor ac
knowle d ge d his poor d iabe te s c
ontrol bu t d id not ad ju s t his
m e d ic
ations .
hronicc
are c
linicand ins u lin was ad d e d . B lood work was ord e re d in fou r
we e ks and follow u pin 5-6we e ks . H e was s e e n on 11/6, bu t the d oc
torind ic
ate d that s he d id not
have the labre s u lts (thou ghthe y had be e n re s u lte d on 10/31)and s o re s c
he d u le d him for
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 15
11/21. She note d his e le vate d A 1cfrom the m onth prior bu t m ad e no c

hange s , give n that his
finge rs tic
ks we re im prove d .
H e was ne xt s e e n on 1/15/14in c
hronicc
are c
linic
. T he re we re no ne w labs s inc
eO c
tobe rand no
c
hange s we re m ad e to his re gim e n.
Opinion:T his patient had m u ltiple inte rru ptions in c
are d u e to c
u stod y and s taffingiss u e s . H is
d iabe te s d oe s not appe arto have be e n m anage d as aggre s s ive ly as his poord ise as e c
ontrolwou ld
m e rit. B lood work has not be e n we llc
oord inate d withc
linicvisits .
HIV Infection/AIDS
T he re we re 15H IV infe c
te d patients at the tim e ofou rvisit, allofwhom we re m anage d e ntire ly by
the ID c
ons u ltant viate le m e d ic
ine ;the ons ite c
linic
ians we re c
om ple te ly u ninvolve d in the c
are
and m onitoringofpatients H IV d ise as e . T his inc
lu d e s e ve n the prim ary c
are as pe c
ts ofthe d ise as e ,
su c
has m onitoringfor m e d ic
ation s id e e ffe c
ts , c
om plianc
e and c
om plic
ations re s u ltingfrom the
d ise as e and its tre atm e nt, s u c
has hype rlipid e m iaand c
ard iovas c
u lard ise as e , whic
hare inhe re ntly
prim ary c
are iss u e s . W e think it is am istake not to e nrollthe s e patients in the c
hronicd ise as e
program in the ide ntic
alway that othe rpatients are e nrolle d , be c
au s e the e nd re s u lt is that this highrisk popu lation is be ingm onitore d le s s d ilige ntly than othe rpatients withc
hronicillne s s e s , d e s pite
the irbe ingm ore vu lne rable in m any c
as e s .
T he re was ad istu rbingpatte rn oftre atm e nt inte rru ption and d e lays in s pe c
ialty c
are in the c
harts
that we re viewe d . T he d oc
u m e ntation in the s e c
harts was in alangu age ofblam ingthe patient for
ru nningou t ofm e d ic
ation in ne arly allc
as e s . C ons id e ringthe re are only ahand fu lofH IV patients
at this fac
ility, the re is no re as on that the y c
annot be m onitore d c
los e ly e nou gh to e ns u re that
tre atm e nt inte rru ptions d o not oc
c
u r. T he m ajority ofthe re c
e nt ord e rs he e ts had be e n thinne d from
the he althre c
ord s , re nd e ringit d iffic
u lt orim pos s ible to d e te rm ine ifm e d ic
ations we re re ne we d
tim e ly orthe s pe c
ialist
s re c
om m e nd ations we re followe d prom ptly afte rte le m e d icine e nc
ou nte rs .
W e re viewe d s ix rand om re c
ord s (40% ) of patients with H IV infe c
tion. O f the 27 c
linic
appointm e nts forwhic
hthe s e patients we re s c
he d u le d , only 10we re c
om ple te d , forac
anc
e llation
rate of63% . T he s e c
as e s are d e s c
ribe d be low.
Patient #6
T his is a38-ye ar-old m an who was d iagnos e d withH IV /A ID S on 7/31/13, at whic
htim e his C D 4
c
ou nt was e xtre m e ly low at 3. T he P A s aw him on 8/6, ord e re d appropriate labs and re fe rre d him
to ID te le m e d ic
ine . H e was s c
he d u le d for8/23, bu t not s e e n d u e to loc
kd own. H e was s c
he d u le d to
s e e the M e d ic
alD ire c
toron 8/22, bu t was not s e e n d u e to aloc
kd own. H e was re s c
he d u le d for9/11,
bu t again not s e e n d u e to loc
kd own.
O n 9/13, he was s e e n by ID te le m e d ic
ine , who rec
om m e nd e d he s tart on B ac
trim , A z ithrom yc
in
and A triplau rge ntly. T he ord e rform s had be e n thinne d from the he althre c
ord s o it was not pos s ible
to d ete rm ine ifthe re c
om m e nd ations we re followe d tim e ly. T he ID d oc
torwante d to s e e the patient
bac
k in s ix we e ks , bu t the ne xt te le m e d ic
ine d id not oc
c
u ru ntilJanu ary.
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 16
H e was finally s e e n by the M e d ic

alD ire c
toron 10/3. P re s u m ably, he had re c
e ntly s tarte d on H IV
the rapy, bu t the re was no d isc
u s s ion re gard ings id e e ffe c
ts , c
om plianc
e , etc
. T he re was m inim al
phys ic
ale xam only ac
om m e nt on his s kin ras h.
O n 10/17, the P A wrote anote s tatingthat s he was inform e d by the patient
s friend that the patient
was ou t ofhis m e d ic
ation. H e was not s e e n again u ntil1/3/14, whe n an R N qu ote d him as s aying
Som e tim e s I d on
t always ge t m y m e d ic
ation.T he re are no othe rnote s in the c
hart, any c
hronic
c
are form s orbas e line intake forc
hronicc
are c
linic
.
O n 1/7, he was s e e n in follow u p by ID te le m e d ic
ine , who note d that the patient ru ns ou t of
m e d ic
ation forabou t awe e k e ac
hm onth. T he c
ons u ltant d id not have ac
c
e s s to the m os t re c
e nt labs
whic
hhad be e n d rawn on 1/3, bu t we re not re s u lte d u ntil1/9.
Opinion:T his patient has had s ignific
ant d e lays in ac
c
e s s ingc
are withre gard to s pe c
ialty follow
u pand s e riou s m e d ic
ation inte rru ptions . It is ofc
ru c
ialim portanc
e that patients not m iss d os e s or
ru n ou t of H IV m e d s , as this is highly as s oc
iate d with tre atm e nt failu re and ad ve rs e ou tc
om e s .
P atients who are ne wly s tarte d on the rapy ne e d to be s e e n within afe w we e ks to e valu ate for
m e d ic
ation s id e e ffe c
ts and c
om plianc
e with the rapy. P atients who are ne wly d iagnos e d ne e d
partic
u larly c
los e m onitoringand s u pport.
Patient #7
T his is a54-ye ar-old m an withH IV infe c
tion s inc
e 2004who arrive d at State ville on 3/13/13. H e
was s e e n in ID te le m e d ic
ine on 4/8, at whic
htim e no ne w labs we re available . H e was following
u pforan inc
re as e d viralload from the priorvisit, thou ght to be d u e to m iss e d d os e s , s o ne w labs
we re e s s e ntial to this visit. T he ID d oc
tor the re fore re qu e ste d that the s e be d one and faxe d
im m e d iate ly and the patient be s e e n again in thre e m onths . Ins te ad , he was s c
he d u le d for8/23(fou r
m onths late r), bu t not s e e n d u e to loc
kd own. H e was re s c
he d u le d for9/13, bu t m arke d no s how
forH IV te le m e d d u e to s e c
u rity.A nu rs e
s note state s he was s e e n on 9/16, bu t the re was no re port
in the c
hart. T he ne xt c
linicwas s c
he d u le d forN ove m be rbu t took plac
e on 12/18.
T he re we re no ons ite provide rnote s in the c
hart at all.
Opinion: T his patient has not be e n s e e n tim e ly in ID c
linicand the re have be e n d isru ptions in his
m e d ic
ation c
ontinu ity. Labs have not be e n c
oord inate d withthe ID te le m e d ic
ine visits and he has
re c
e ive d e s s e ntially no prim ary c
are s inc
e his arrivalne arly aye arago.
Patient #8
T his is a50-ye ar-old m an withH IV , e nd s tage re nald ise as e on d ialys is, he patitis C , hype rte ns ion,
hype rlipid e m ia, SC trait and late nt T B infe c
tion who was d iagnos e d withH IV in 1997. H e has be e n
s e e n tim e ly fortwo ofthe las t thre e ID c
linic
s , the m os t re c
e nt be ingin D e c
e m be r2013. T he late s t
c
linicwas d e laye d d u e to c
u s tod y re as ons . H is viralload has be e n s u ppre s s e d forat le as t the pas t
ye arand he has be e n c
om pliant withm e d ic
ations .
Patient #9
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 17
T his is a55-ye ar-old m an withad vanc

e d H IV , firs t d iagnos e d in 1994, who is on d e e ps alvage
the rapy. H e als o has d iabe te s , hype rte ns ion, c
oronary arte ry d ise as e and hype rlipid e m ia, bu t his
proble m list m e ntions only d iabe te s and hype rte ns ion.
A t the 8/5/13ID te le m e d ic
ine visit, the patient re porte d that he had only be e n ge ttinghalfatable t
ofhis Inte le nc
e ;it s hou ld have be e n 200m gtwic
e ad ay bu t on the M A R it s hows that fors e ve ral
m onths it was ord e re d as 100m gtwic
e ad ay. T he ord e rs he e ts had be e n thinne d from the re c
ord .
A t the follow-u pvisit in D e c
e m be r, (one m onthove rd u e ), this iss u e was not ad d re s s e d . T he m ore
re c
e nt M A R s re fle c
t the appropriate d os e .
Opinion:C ons ide ring that the patient
s tre atm e nt options are ve ry lim ite d at this point, the
m agnitu d e ofthis e rrorwas partic
u larly gre at.
Patient #10
T his is a51-ye ar-old m an withe nd s tage re nald ise as e on d ialys is and H IV infe c
tion who arrive d
at State ville on 10/9/13, bu t has ye t to be s e e n by afac
ility provide rs inc
e his arrival. H e was s e e n
by ID te le m e d ic
ine on 12/18and the provid e rre qu e s te d labs , bu t it d oe s not appe arthat the s e we re
ord ere d . In fac
t, the re we re no labs in the c
hart s inc
e the patient arrive d at State ville .
Opinion:T his patient has not had blood work d one tim e ly and has not be e n s e e n by aprovide rat
the fac
ility s inc
e his arrival.
Patient #11
T his is a47-ye ar-old H IV patient who has only be e n s e e n onc
e in the pas t ye arby afac
ility provid e r.
T his was in Ju ne of2013whe n he was s e e n by the P A at the patient
s re qu e s t be c
au s e he m iss e d
his labappointm e nt and his he m orrhoid s we re bothe ringhim . H IV labs we re ord e re d that visit bu t
the patient was ne ve rs e e n by afac
ility provid e ragain.
H e was s e e n in ID te le m e d ic
ine c
linicin A pril2013 at whic
htim e athre e m onthfollow u p was
re qu e s te d . Ins te ad , he was s c
he d u le d fou r m onths late r on 8/6, bu t was ano s how. H e was
re s c
he d u le d for 8/23, bu t was not s e e n d u e to loc
kd own. O n 9/13, he was ano s how for H IV
te le m e d c
linicd u e to s e c
u rity. H e was s e e n on 9/16 pe r anu rs e note, bu t the re was no c
ons u lt
re port in the c
hart. H is m os t re c
e nt ID note was on 12/18.
Opinion:T his patient has not be e n re c
e ivingad e qu ate prim ary c
are . H is H IV c
are has als o not be e n
tim e ly.
Pulmonary
W e pe rform e d ad e taile d c
hart re view offive rand om re c
ord s ofpatients e nrolle d in the pu lm onary
c
hronicc
are c
linic
. In e ve ry c
as e , m u ltiple c
hronicc
linicvisits we re c
anc
kd owns or
the abs e nc
e ofthe provide r. O n ave rage , 38% ofs c
he d u le d appointm e nts we re c
anc
e lle d d u e to
loc
kd owns or no provide r. If no-s hows are als o c
ons id e re d , the proportion of m iss e d
appointm e nts e xc
e e d s halfofalls c
he d u le d appointm e nts (53% )forthis s am ple .
Patient #12
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 18
T his is a33-ye ar-old m an withpoorly c

ontrolle d as thm a. A tte m pts at provid ingc
hronicd ise as e
c
are ove rthe pas t ye arhave be e n as follows :
2/12/13 C anc
e lle d d u e to no provide r
2/13 N o s how
2/16 Loc
kd own
3/6 N o provide r
3/23 N o s how
5/11 N o s how
6/4 P atient was s e e n. A t this point, he was u s inghis re s c
u e inhale rd aily d u e to alle rgies .
H is pe ak flow was 540 and he was d e e m e d to be u nd e r fair c
ontrol. Loratad ine and
N as one x we re ad d e d .
11/8 N o s how
11/14 N o provide r
12/3 Se e n. H e was u s inghis re s c
u e inhale rm u ltiple tim e s d aily. P e ak flow re ad ings we re
s om e what low at 520/500/490. W he e z ingwas he ard on e xam and his s te roid inhale rwas
inc
re as e d .
2/6/14 Le ft withou t be ings e e n
2/11 Still u s inghis re s c
u e inhale r d aily. P e ak flow abit low at 520/500/480. M e d s
re ne we d . Longd isc
u s s ion re gard ingm e d ic
ation u s age .
T he re we re no u ns c
he d u le d visits forre s piratory s ym ptom s .
Opinion:T his patient
s as thm a is poorly c
ontrolle d give n his d aily u s e of the re s c
u e inhale r.
T he re fore , he s hou ld have be e n s e e n m ore fre qu e ntly for m onitoringand m e d ic
ation ad ju s tm e nt.
T he m ajority ofhis s c
he d u le d c
hronicc
are visits d id not take plac
e forvariou s re as ons inc
lu d ing
no s how,whic
hs hou ld be u nhe ard ofin am axim u m -s e c
u rity prison.
Patient #13
ontrolle d as thm a. H e was s c
he d u le d to be s e e n 12 tim e s
ove rthe pas t ye ar, bu t only fou rofthe s e appointm e nts we re c
om ple te d . O n fou roc
c
as ions , he was
not s e e n d u e to no provide r, inc
lu d ingone oc
c
as ion whe re this was pe rs onally writte n by the
d oc
tor. O n thre e oc
c
as ions he was m arke d no s how and one visit was c
anc
e lle d d u e to a
loc
kd own.
O n thre e ofthe fou roc
c
as ions that he was s e e n, he was u s inghis re s c
u e inhale r m u ltiple tim e s a
d ay and re qu ire d inte ns ific
ation ofhis tre atm e nt regim e n.
D u ringhis 11/1/13 visit, he was u s inghis inhale r fou r tim e s pe r d ay and re porte d ly c
ou ghing
nons top.H e was whe e z ingon e xam . M e d ic
ations we re ad d e d and afou r-we e k follow-u pvisit was
re qu e s te d ;howe ve r, he was not s e e n again for31/2m onths d u e to thre e no s hows and aloc
kd own.
Opinion:T his patient has not re c
e ive d tim e ly c
are forhis poorly c
ontrolle d as thm a.
Patient #14
T his is a45-ye ar-old m an withas thm a. H is c

hronicc
are ove rthe pas t ye aru nfold e d as follows :
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 20
19
O n 2/1/13, the patient was s e e n forhis annu alc

hronicc
are visit. H e re porte d that his las t as thm a
attac
k was alongtim e agoand that he had ru n ou t ofbothhis inhale rs fou rm onths ago. H is pe ak
flows we re low at 450/450/400. T he re was no whe e z ingon e xam . Give n his re porte d ly good
c
ontrol, his inhale d s te roid was d isc
ontinu e d and the albu te rolre ne we d .
O n 6/1, he re porte d no re c
e nt attac
ks bu t was u s inghis re s c
u e inhale rtwic
e ad ay. H is pe ak flows
we re low at 450/450/450. Lu ngs we re c
le ar. H is inhale d s te roid was re ne we d and ac
he s t x-ray was
ord ere d .
O n 8/21, he was s c
he d u le d bu t not s e e n d u e to aloc
kd own.
O n 10/22, he reporte d that he had be e n u s ingthe re s c
u e inhale r3-4tim e s pe rd ay bu t ran ou t fou r
m onths ago. H is pe ak flows we re low at 250/355/400. T he inhale d ste roid was inc
re as e d and the
re s c
u e inhale rwas reord e red . T he patient was d isc
ou rage d from ove ru s inghis re s c
u e inhale r.
O n 10/28, he was not s e e n d u e to no provid e r.
A t the 2/4/14visit, he re porte d that he was u s inghis re s c
u e inhale rtwic
e ad ay. P e ak flows we re
low at 400/400/425and loratad ine was ad d e d .
Opinion:T his patient s hou ld not have ru n ou t ofhis inhale rs . It s e e m s d istinc
tly pos s ible that the
patient was ove ru s inghis inhale rbe c
au s e his as thm awas poorly c
ontrolle d .
Patient #15
T his is a59-ye ar-old m an withas thm a. In the pas t ye ar, he was s c
he d u le d nine tim e s and s e e n on
five oc
c
as ions . T wic
e he was not s e e n d u e to no provide r,onc
e d u e to aloc
kd own, and onc
e he
le ft withou t be ings e e n. T hou gh his pe ak flows we re low, he was re lative ly as ym ptom aticu ntil
O c
tobe r2013, whe n he e xpe rienc
e d an e xac
e rbation d u e to alle rgies . H e was tre ate d appropriate ly
and re fe rre d to nu rs e s ic
kc
allforfollow u p.
Opinion:T his patient had m u ltiple inte rru ptions in his c
hronicc
linicvisits .
B os we llP harm ac
e u tic
als , loc
ate d in P e nns ylvania, provide s allpre s c
ription and ove r-the -c
ou nte r
m e d ic
ations forthe fac
ility. T he s e rvic
e is afax and fills ys te m , whic
hm e ans patient pre s c
riptions
faxe d to the pharm ac
y tod ay by 2:00 p.m . willarrive at the fac
ility the ne xt d ay. P atient s pe c
ific
pre s c
riptions , s toc
k pre s c
riptions and c
ontrolle d m e d ic
ations arrive pac
kage d in a31-d ay bu bble
pac
k. O ve r-the -c
ou nte rm e d ic
ations are provide d in bu lk by the bottle , tu be , etc
. A loc
albac
k-u p
pharm ac
y is u s e d to obtain m e d ic
ation whic
his ne e d e d im m e d iate ly and is not available in s toc
k.
T he m e d ic
ation s torage are a is s taffe d with one fu ll-tim e pharm ac
y te c
hnic
ian, and B os we ll
provide s ac
ons u ltingpharm ac
ist to c
om e on-s ite onc
e am onthto re view pre s c
ription ac
tivity, to
as s e s s pharm ac
y te c
hnic
ian pe rform anc
e and te c
hniqu e and to d e s troy ou td ate d orno longe rne e d e d
c
ontrolle d m e d ic
ations pu rs u ant to the re qu ire m e nts ofthe
Fe d e ral D ru gA d m inistration (FD A ) and D ru gE nforc

e m e nt A ge nc
y (D E A ). Ins pe c
tion of the
m e d ic
ation s torage are are ve ale d ac
le an, we ll-lighte d and ge ne rally we ll-m aintaine d are a. A n
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 21
inte rview withthe pharm ac

y te c
hnician re ve ale d aknowle d ge able ind ivid u al. Ins pe c
tion ofthe
are a ind ic
ate d tight ac
c
ou nting of c
ontrolle d m e d ic
ations , both s toc
k and re tu rn ite m s ,
ne e d le s /s yringe s , s harps /ins tru m e nts and m e d ical tools . A rand om ins pe c
tion of pe rpe tu al
inve ntories and c
ou nts ind ic
ate d allwe re c
orre c
t. Ins pe c
tion ofthe m e d ic
ation pre paration room
re ve ale d a c
le an, we ll-lighte d and we ll-m aintaine d are a. A rand om ins pe c
tion of pe rpe tu al
inve ntories ind ic
ate d allwe re c
orre c
t. M e d ic
ation is ad m iniste re d by re giste re d nu rs e s (R N )and
lic
e ns e d prac
tic
alnu rs e s (LP N ). D u e to the c
e llhou s e s be ingm u lti-tiere d and not havinge le vators ,
nu rs ings taff are u nable to take m e d ic
ation c
arts to the c
e ll hou s e s or ad m iniste r m e d ic
ation
d ire c
tly from the patient s pe c
ificbu bble pac
k. Ins te ad , the nu rs e take s the appropriate d os e from
the bu bble pac
k and plac
e s it in as m allm e d ic
ation e nve lope whic
h has be e n labe le d with the
inm ate
s nam e , nu m be r, nam e ofthe m e d ic
ation, the s tre ngth, the d os age and the c
e llnu m be r. T he
nu rs e the n proc
e e d s to e ac
hc
e llhou s e , re ports to s e c
u rity and is provid e d as e c
u rity e s c
ort to go
c
e ll-to-c
e ll. T he c
e llhou s e s have ope n-barre d d oors . T he inm ate is re s pons ible to c
om e to the d oor
withabe ve rage and id e ntific
ation. T he nu rs e pos itive ly id e ntifies the inm ate , pou rs the pills into
the inm ate
s hand and obs e rve s as the inm ate take s the m e d ic
ation, d rinks and s wallows . T he nu rs e
the n c
ond u c
ts am ou thc
he c
k to as s u re the inm ate has s wallowe d the m e d ic
ation. T he nu rs e re pe ats
this proc
e s s u ntilallm e d ic
ations are ad m iniste re d . W he n c
om ple te d , the nu rs e re tu rns to the he alth
c
are u nit and d oc
u m e nts the ad m inistration, re fu s alor abs e nc
e on apatient-s pe c
ificm e d ic
ation
ord (M A R ). O bs e rvation ofthe proc
e s s re ve ale d ad m inistration by aLP N , who
prope rly id e ntified the patients , ad m iniste re d the m e d ic
ation, obs e rve d the inge s tion, pe rform e d a
m ou thc
he c
k and d oc
u m e nte d the ad m inistration on the M A R . E ve n thou ghit is ins titu tionalpolicy
that s e c
u rity s taffe s c
orts nu rs ings taffd u ringm e d ic
ation ad m inistration, afte rapproxim ate ly 10
m inu te s , the s e c
u rity offic
e rle ft the nu rs e and d id not re tu rn. T he nu rs e c
ontinu e d withm e d ic
ation
ad m inistration u ntilthe c
e llhou s e was c
om ple te d .
Laboratory
Laboratory s e rvic
e s are provid e d throu ghthe U nive rs ity ofIllinois-C hic
ago H os pital(U IC ). T he
c
om pre he ns ive s e rvic
e s m e d ic
alc
ontrac
torprovid e s 0.5FT E ofphle botom y to d raw and pre pare
the s am ple s for trans port to U IC . R e s u lts are e le c
tronic
k to the fac
ility,
ge ne rally within 24 hou rs vias e c
u re fax line loc
ald e partm e nt. T he re we re no
e ;howe ve r, the phle botom y pos ition s hou ld be inc
re as e d
to 1.0 FT E . U IC re ports allre portable c
as e s to both the fac
ility and the Illinois D e partm e nt of
P u blicH e alth. T he re is ac
u rre nt C linic
alLaboratory Im prove m e nt A m e nd m e nt (C LIA )waive r
c
e rtific
ate that e xpire s Ju ne 13, 2015 on file . T he re we re no re ports of any proble m s with this
s e rvic
e.
Urgent/Emergent
Care
Offsite Services/Emergencies
W e re viewe d s ix re c
ord s of patients s e nt offs ite on an e m e rge nc
y bas is. Fou r of the re c
ord s
d e m ons trate c
onc
e rns withre gard to e ithe r the res pons e s ons ite prior to the s e nd ou t or the c
are
followingre tu rn. A c
om m on patte rn throu ghou t is the abs e nc
e ofe m e rge nc
y room re ports .
Patient #1
T his is a32-ye ar-old m ale withapriorope n re d u c
tion and inte rnalfixation ofthe hu m e ru s afte ra
m otorve hic
le ac
c
id e nt in 2002. O n 11/14/13, while liftingwe ights in the gym , abarbe llac
c
id e ntly
s tru c
k his he ad . H e c
am e to the m e d ic
al u nit and was tre ate d s ym ptom atic
ally and was to be
followe d u p in five d ays . O ne d ay late rhe c
om plaine d ofs e ve re he ad ac
he and d izz ine s s . H e was
give n c
oolc
om pre s s e s and re fe rre d to the phys ic
ian. W he n s e e n by the phys ic
ian thre e d ays late r
on 11/18, he was give n am e d ic
ine u s e d to tre at m igraine s fortwo we e ks . A d ay late ran ord e rwas
writte n for alay-in and s ku llx-rays alongwithc
old c
om pre s s e s and he was to be re e valu ate d in
two d ays . O n 11/20, he c
ontinu e d to c
om plain ofd izz ine s s and s o he was re fe rre d to R N s ic
kc
all
to be s e e n on 11/23. H owe ve r, his visit from 11/23 was re s c
he d u le d to 11/25 and the n to 11/27.
M e anwhile , be c
au s e ofs e ve re s ym ptom s , on 11/21he was s e nt to the e m e rge nc
y room , whe re he
finally re c
e ive d abrain s c
an. Fortu nate ly, the s c
an was ne gative and he re tu rne d to the prison and
was s e e n on re tu rn by the phys ic
ian. In ou r view the re was as ignific
ant d e lay in ac
c
e s s ingthe
ne c
e s s ary C T s c
an whic
hc
ou ld have e arly on provid e d s om e re as s u ranc
e withre gard to the natu re
ofhis proble m .
Patient #2
T his is a78-ye ar-old m ale withas thm a, hype rlipid e m ia, ahistory ofahe art attac
k and hype rte ns ion.
O n 11/19/13, he c
om plaine d ofc
he s t pain and was s e nt ou t afe w hou rs late rand retu rne d fou rd ays
late rfrom St. Jos e ph
s H os pital. O n re tu rn he was s e e n by anu rs e and s e nt to the infirm ary. T he re
we re s om e hos pitalre c
ord s in the c
hart, bu t m os t im portantly no d isc
harge s u m m ary. Se ve rals taff
inform e d u s that it was d iffic
u lt ifnot im pos s ible to obtain ad isc
harge s u m m ary from patients s e nt
to St. Jos e ph
s H os pital. T his patient was ad m itte d for23hou rs to the infirm ary and was d isc
harge d
one d ay late r. T he re is anote writte n in the c
hart by the phys ic
ian whic
h d oe s not m e ntion the
patient
s re le as e to the hou s ingu nit. T his patient
s pain pe rs iste d and the patient was s e e n on
1/17/14 in the c
hronicc
are c
linic
. A t that tim e , he ind ic
ate d that he was u s ingnitroglyc
e rin for
c
he s t pain d aily. H is lipid s we re e le vate d . T he patient was re fe rre d to the phys ic
ian bu t stillhad not
be e n s e e n as of2/19. T he M e d ic
alD ire c
torwho te nd s to s e e the s e c
as e s is booke d u pforalittle
m ore than am onth. A fte rou rd isc
u s s ion this patient was s e e n on 1/24by the phys ic
ian.
Patient #3
T his is a 64-ye ar-old m ale with c
oronary arte ry d ise as e and prior ste nt plac
e m e nt alongwith
hype rlipide m ia, be nign prostatichype rtrophy, rhe u m atoid arthritis and apriorc
hole c
ys te c
tom y. O n
12/6/13, he was s e nt ou t as apos s ible s troke. H e pre s e nte d withs wolle n hand s and wrists and asore
ne c
k alongwith afac
iald rop and he was ve ry s low to re s pond . H e was s e nt to the hos pitalvia
am bu lanc
e and retu rne d afe w d ays late r. T he re is no d isc
harge s u m m ary available ;the re was als o
no nu rs ingnote u pon retu rn. A ppare ntly the hos pitald iagnos is was rhe u m atoid arthritis, a
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 22
flare -u p, whic
hd oe s not re ally e xplain his s low re s pons ive ne s s . H e was followe d u pby an ad vanc
ed
le ve lc
linic
ian on 2/11and 2/16.
Patient #4
T his is a 53-ye ar-old m ale with a history of s e izu re s , c
hronicc
he s t pain and m u ltiple s te nt
plac
e m e nts . H e has prove n to be ad iffic
u lt patient, with inte rm itte nt re fu s alof blood pre s s u re
m e d ic
ine s whic
hthe n te nd s to le ad to an e le vate d blood pre s s u re and the pre s e nc
e ofc
he s t pain.
H e was ad m itte d to the infirm ary on 7/1/13foras e ve re ly e le vate d blood pre s s u re and re le as e d a
d ay late rwhe n the blood pre s s u re re tu rne d to norm al. H e als o has oc
c
as ionally be e n u nc
oope rative
withre gard to vitals igns . O n 7/15, he re fu s e d his m e d s be c
au s e the y we re c
ru s he d d u e to prior
proble m s . H e was c
ou ns e le d and s c
he d u le d to s e e the phys ician 10d ays late r, bu t ad ay late rhis
blood pre s s u re was fou nd to be low as was his pu ls e and he was lighthe ad e d . So he s aw the
phys ician u rge ntly and the phys ician d isc
ontinu e d the u s e ofc
ru s he d m e d ic
ations . H e was plac
ed
in the infirm ary for obs e rvation. O n 7/26, he was note d to be in poor c
ontrolwithre gard to his
hype rte ns ion and on are c
he c
k one hou r late r he was s tillpoorly c
ontrolle d . D e s pite this he was
re le as e d to his c
e llhou s e . A t 10:00p.m . the s am e d ay he was c
om plainingofs e ve re c
he s t pain.
T he phys ician was c
alle d and the patient was plac
e d in the infirm ary forobs e rvation. T he blood
pre s s u re at that tim e as we llas are pe ate d blood pre s s u re d e m ons trate d poorc
ontrol. D e s pite the
poor c
ontrol, he wishe d to re tu rn to his c
e llhou s e . A d ay late r, he ind ic
ate s he fe e ls his blood
pre s s u re is highand in fac
t it was s e ve re ly e le vate d , alongwitharapid pu ls e rate . A phys ician on
c
allin the e ve ningord e re d m e d ic
ations , whic
hwe re not s u c
c
e s s fu lin c
ontrollingthe pre s s u re for
the ne xt thre e d ays . D e s pite this he was e ve ntu ally re tu rne d to the c
e ll hou s e . O n 9/18, he
c
om plaine d ofd izz ine s s and his blood pre s s u re was fou nd to be e xtre m e ly low. H e was give n IV
flu id s and s e nt to the hos pitaland re tu rne d five d ays late r. A t the tim e ofre tu rn, his blood pre s s u re
was e le vate d bu t he had no c
om plaints . H e was s e nt forobs e rvation in the infirm ary and s e e n by
the M D one d ay late r. A gain, the re is no d isc
harge s u m m ary from the hos pitalization. T he abs e nc
e
oftim e ly orany d isc
harge s u m m aries and als o e m e rge ncy room re ports c
le arly c
om prom ise s the
ability ofthe ons ite s taffto tim e ly and appropriate ly follow u pon patient ne e d s .
Scheduled Offsite Services-Consultations/Procedures

W e we re inform e d that whe n an ad vanc
e d le ve lc
linic
ian ord e rs ac
ons u ltation oraproc
e d u re it is
re viewe d by the ons ite M e d ic
alD ire c
tor and if he c
onc
u rs it is s u bm itte d to the W e xford U M
program and d isc
u s s e d on M ond ays withaphys ic
ian in W e xford
s c
e ntraloffic
e . W e we re als o
told that ifit is not approve d , an alte rnate plan is re c
om m e nd e d . U ltim ate ly, onc
e the approvalis
obtaine d the W e xford c
e ntral offic
e c
ontac
ts U IC for the s c
he d u lingof the appointm e nt. W e
le arne d , howe ve r, that s om e tim e s m ore than am onth c
an e laps e afte r the approvalbe fore U IC
re c
e ive s the inform ation re gard ingthe approval.
ord s of patients s c
he d u le d for e ithe r a c
ons u ltation or a proc
e d u re . W e
re viewe d the s e re c
ord s withre gard to the appropriate ne s s and tim e line s s ofthe re qu e s t as we llas
the tim e line s s ofthe s e rvic
e and the appropriate ne s s ofthe follow u pons ite . Six ofthe nine re c
ord s
d e m ons trate d proble m s .
Patient #1
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 23
T his is a23-ye ar-old m ale withtype 2 d iabe te s and hype rte ns ion alongwithd iabe ticne u ropathy
and s tage 4c
hronickid ne y d ise as e . In ad d ition, he als o had e ros ive gas tritis. O n 10/30/13, he was
sc
he d u le d foravas c
u lars u rge ry c
ons u lt re gard inghis c
hronickid ne y d ise as e . T he re is no re port in
the c
hart and no m e ntion in any progre s s note s inc
e . T he patient d id go to the c
linicbu t the re has
be e n no follow u p.
Patient #2
T his is a51-ye ar-old m ale withtype 2 d iabe te s m e llitu s who was s c
he d u le d foran e ar, nos e and
throat c
ons u ltation on 10/30/13. H e had be e n s e nt the re be c
au s e ofd iffic
u lt to c
ontrole pistaxis. H e
s aw the E N T s pe c
ialist and the re is anu rs ingnote u pon retu rn, bu t the re has be e n no phys ic
ian
follow u pand no ord e rs writte n c
ons iste nt withthe E N T re c
om m e nd ations .
Patient #3
T his is a53-ye ar-old withno c
hronicproble m s who was s c
he d u le d forthe vas c
u larlabon 11/1/13.
T he re is anote by the phys ic
ian as s istant re gard ingthe pre -opm e d s and the vas c
u larnote is in the
c
hart. T he re has be e n no follow u ps inc
e by aphys ic
ian.
Patient #4
T his is a39-ye ar-old withs c
olios is who was re fe rre d to ortho and had an appointm e nt s c
he d u le d
for10/28/13. T he re port d e m ons trate d ale ft m e nisc
u s te arforwhic
han M R I ofthe kne e and the C
s pine we re re c
om m e nd e d , alongwithan E M G ofthe le ft u ppe re xtre m ity. T he re is anu rs e re tu rn
note bu t no phys ic
ian follow u pnote and no ord e rs .
Patient #5
T his is a70-ye ar-old who had aGU appointm e nt s c
he d u le d for11/6/13. T his was to follow u pon
prostate c
anc
e r, whic
hd id not appe aron his proble m list;the list d id inc
lu d e glau c
om a. T he re port
ind ic
ate s that the patient ne e d s aC T s c
an and abone s c
an. T he re is no phys ic
ian follow u pnote bu t
the re is anu rs e note whic
hind ic
ate s the patient we nt forthe C T s c
an, bu t the re is no re port from
the C T s c
an norare the re any follow u pnote s by aphys ic
ian.
Patient #6
T his is a47-ye ar-old m ale withs ic
kle c
e lltrait and asthm awho was s e nt to ge ne rals u rge ry foran
appointm e nt on 10/28/13foran e valu ation ofaright ingu inalhe rnia. T he patient we nt and the re is
aretu rn note by are giste re d nu rs e. T he re is are port from the ge ne rals u rgeon in the c
hart whic
h
re c
om m e nd s right ingu inalhe rniaroboticrepair. The re has be e n no follow u pofany kind .
Infirmary
T he infirm ary is loc
ate d within the H e althC are U nit. T he infirm ary floorplan is are c
tangle , two
longhallways and two s hort hallways . T he nu rs ings tation is loc
ate d in the c
e nte rofthe re c
tangle
and has ac
c
e s s to bothlonghallways . P atient room s are loc
ate d alongthe ou te rpe rim e te rofthe
re c
tangle . A c
c
e s s to the infirm ary is c
ontrolle d by s e c
u rity s taffpos te d ju s t ou ts id e the infirm ary.
T he u nit is s taffe d 24 hou rs ad ay, s e ve n d ays awe e k. Staffingc
ons ists ofbothR N s and LP N s
withat le as t one R N on d u ty e ac
hs hift. T he re are atotalof32 infirm ary be d s c
onfigu re d as 10
s ingle c
e lls and 11 d ou ble c
e lls . Inc
lu d e d in the c
e llc
onfigu ration are two ne gative air pre s s u re
re s piratory isolation room s .
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 24
T he be d s in the 10s ingle room s are an all-m e talfram e withathin plas ticc
ove re d m attre s s and 18
to 24inc
he s offthe floor. T he be d s in the re m aininge le ve n room s are ac
om bination oftrad itional
s ingle be d s and hos pitalbe d s . O nly five ofthe s e 22be d s allow forthe he ad orfoot to be e le vate d .
T he s e be d s d o have athic
ke r plas ticc
oate d m attre s s and are loc
ate d highe r offthe floor. O n the
d ay ofthe ins pe c
tion, the re we re atotalof28patients c
las s ified as follows :
1. Five m e ntalhe alth
2. O ne hu ngerstrike
3. T wo ac
u te c
are patients ;one u nc
ontrolle d d iabe ticand one follow-u p he art attac
k and
u nc
ontrolle d blood pre s s u re
4. T we nty c
las s ified as c
hronicc
are
A s re porte d by nu rs ings taff, the patients re qu iringthe m os t c
are are note d as follows :
1. T wo paraple gicpatients
2. O ne patient withc
anc
e rofthe prostrate whic
hhas m e tas tas ize d to the s pinalc
ord
3. O ne post-stroke patient
4. O ne A lz he im e rpatient
5. O ne c
anc
e rpatient
A re view ofthe m e d ic
alre c
ord s ofthe patients in the s e five c
ate gories re ve ale d m ore fre qu e nt visits
and d oc
u m e ntation by the phys ic
ian than re qu ire d by polic
y. N u rs ings taff, too, was d oc
u m e nting
m ore fre qu e ntly than re qu ire d by polic
y. R e view ofthe d oc
u m e ntation ind ic
ate d provide rs pe c
ific
iss u e s as to the fre qu e nc
y, qu ality and c
om ple te ne s s ofd oc
u m e ntation. Inm ate porters pe rform the
hou s e ke e ping/janitoriald u ties and are s u pe rvise d by bothnu rs ingand s e c
u rity s taff. T he re is no
e vid e nc
e inm ate porte rs re c
e ive any s pe c
ialize d trainingin re gard to appropriate c
le aningand
s anitizingin the he althc
are u nit.
T he re is a 32-be d infirm ary. A t the tim e of ou r visit, the re we re 24 State ville inm ate s in the
infirm ary, s ix from N R C and two e m pty be d s . O fthe State ville inm ate s , 14we re c
hronic
/longterm
ad m iss ions , five we re form e ntalhe althre as ons and five we re forac
u te illne s s e s . O ne ofthe s e ac
u te
ad m iss ions was am an on ahu nge rs trike , and two ofthe fou rre m aininghad be e n d isc
harge d the
m orningofou rvisit.
T he M e d ic
alD ire c
tors tate d that he rou nd s d aily bu t d oe s not always write anote . Ind e e d , ac
c
ord ing
to ou rre c
ord re views , it appe are d that patients we re not s e e n as fre qu e ntly as polic
y d ic
tate s , e ithe r
by the phys ic
ian orby the nu rs ings taff. W e als o had c
onc
e rns re gard ingthe qu ality ofthe he alth
c
are provide d to the patients , as ou tline d in the c
as e s be low.
W e re viewe d the followingac
u te ad m iss ions .
Patient #1
oronary arte ry d ise as e who had bypas s
s u rge ry in D e c
e m be r2013and was ad m itte d to the infirm ary u pon his re tu rn on 12/24. T he re we re
tim e ly note s by the M e d ic
alD ire c
toru ntil12/30, bu t the n none fortwo we e ks . O fthe 62
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 25
s hifts the patient s pe nt in the infirm ary, the re we re 23nu rs ingnote s . T he re we re nine d ays whic
h
had no note s by any he althc
are provide r.
O n 1/2/14, an R N note ind ic
ate s that the patient we nt ou t to s e e c
ard iology forfollow u p;howe ve r,
the re is no note from c
ard iology. W he n we re qu e s te d the c
ard iology note s and d isc
harge s u m m ary,
we we re told that bothU IC and St. Joe 's re qu ire an au thorization forre le as e ofinform ation form
be fore the y wills e nd re ports.
Opinion:T his patient was not s e e n ac
c
ord ingto polic
y e ithe r by the phys ic
ian or by the nu rs ing
s taff.
Patient #2
T his is apoorly c
ontrolle d type 1d iabe ticwho was ad m itte d to the infirm ary on 2/4/14ford iabe tic
c
ontrol. H e als o has hype rte ns ion, hype rlipid e m iaand hypothyroid ism . H e was m anage d on twic
ed aily N P H and re gu larins u lin plu s s lid ings c
ale .
A s ofthe d ate ofou rvisit (2/24), he had be e n s e e n on ave rage onc
e pe rwe e k (Fe bru ary 4, 6, 11,
19, 24)by the phys ician. T he re we re nu rs e s note s at le as t d aily on 18ofthe 21d ays he had be e n
in the infirm ary, bu t on thre e d ays , the re we re no note s at all(provid e rornu rs e );Fe bru ary 12, 15,
17.
Shortly afte r his ad m iss ion (2/6), blood work re ve ale d that the patient
s thyroid m e d ic
ation d os e
was too high(low T SH , highT 4). T his re port was s igne d by one phys ic
ian withatte ntion to the
othe r, bu t ne ithe rd oc
torad ju s te d the thyroid m e d ic
ation d os e .
O n the s am e labre port, the patient
s potas s iu m was fou nd to be e le vate d (5.5)and he was on s e ve ral
m e d ic
ations known to c
au s e hype rkale m ia, inc
lu d ingan A C E inhibitorand ald ac
tone . N o c
hange s
have be e n m ad e to the m e d s and the potas s iu m has not be e n c
he c
ke d s inc
e.
Opinion:T his patient was not s e e n tim e ly ac
c
ord ingto polic
y. W e d isc
u s s e d this patient
s lab
abnorm alities withthe M e d ic
alD ire c
tor, who had aplan in m ind , bu t this was not artic
u late d in the
he althre c
ord .
Patient #3
T his patient was ad m itte d for ac
u te c
are on 2/17/14 viate le phone ord e r afte r he was d isc
harge d
from St. Joe 's followingan ac
u te M I. H e was re tu rne d from the hos pitalto State ville on 2/19. Staff
re qu e s te d hos pital re ports bu t we re bas ic
ally provide d only a c
ard iology c
ons u lt and s om e
laboratory re s u lts . N otably abs e nt was ad isc
harge s u m m ary whic
h wou ld have be e n c
ritic
alto
u nd e rs tand ing the hos pital
s find ings and re c
om m e nd ations . T he M e d ic
al D ire c
tor d id the
ad m iss ion note on 2/19and s aw the patient again on 2/24. T he patient
s blood pre s s u re has be e n
u nc
ontrolle d forthe e ntire ty ofhis s tay in the infirm ary, withm u ltiple d ange rou s ly highre ad ings
(170/60, 200/80, 220/78, 190/80, 218/70, 180/68, 210/70, etc
.), bu t the s e re ad ings we re ofte n not
ad d re s s e d .
O n 2/20, the patient
s blood pre s s u re was 220/78and 190/80on re c
he c
k. T he M e d ic
alD ire c
torwas
notified bu t no ne w ord e rs we re obtaine d .
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 26
O n 2/21, the patient

s blood pre s s u re was 170/70and the R N note d M D aware ,bu t took no ne w
ord ers . Late rthat d ay, the LP N c
alle d the M e d ic
alD ire c
torthre e tim e s and le ft m e s s age s forblood
pre s s u re re ad ings of190/80and 160/68, bu t no ne w ord e rs we re re c
e ive d .
O n 2/22, the nu rs e c
ontac
te d the M e d ic
alD ire c
torforablood pre s s u re of201/70and re c
e ive d an
ord erto start hyd roc
hlorthiaz id e 25m g/d . Laterthat e ve ning, the nu rs e c
alle d bac
k to re port that the
blood pre s s u re was u nc
hange d . T he M e d ic
alD ire c
tor re s pond e d by s witc
hingone of his blood
pre s s u re m e d ic
ations to anothe rs im ilard ru g, whic
hre s u lte d in e s s e ntially no c
hange at all.
T he ne xt d ay, the patient
s blood pre s s u re was be tte rinitially (117/52, 124/56)bu t by e ve ningit
was bac
k u pto 188/92.
O n 2/24, the phys ic
ian s aw the patient, whos e blood pre s s u re was 186/84. H e note d , blood pre s s u re
not c
ontrolle d ye t,bu t m ad e no m e d ic
ation c
hange s .
s blood pre s s u re has not be e n m anage d ad e qu ate ly, partic
u larly in light ofhis
re c
e nt he art attac
k.
Patient #4
T his is a60-ye ar-old m ale withahistory ofhype rte ns ion, pe pticu lc
e rd ise as e , he patitis C , C O P D
and he re tu rne d s tatu s post trac
he os tom y. H e was ad m itte d to the infirm ary at State ville afte rre tu rn
from U IC on 1/25/14. In aprogre s s note , his ac
u ity le ve lis d e s c
ribe d by the phys ic
ian bu t the re is
no ord e rand the re we re s e ve rald ays in Fe bru ary withno nu rs ingnote s , inc
lu d ing2/17, 2/18and
2/22. T his c
as e is are fle c
tion ofthe c
onfu s ion arou nd the u s e ofan ac
u ity le ve lthat d e te rm ine s the
m inim alfre qu e nc
y forbothad vanc
e d le ve lc
linic
ian as we llas nu rs ingas s e s s m e nts .
Infection Control
T he re is anam e d infe c
tion c
ontrolnu rs e who is re s pons ible for c
om plianc
e with ID O C policy
c
onc
e rning c
om m u nic
able d ise as e s , blood borne pathoge ns and c
om plianc
e with Illinois
D e partm e nt ofP u blicH e althre portingre qu ire m e nts . A d d itionally, this nu rs e is re s pons ible forthe
H IV and H e patitis C c
linic
s.
T he fac
ility has ac
ontrac
t withalarge nationalm e d ic
alwas te d ispos alc
om pany whic
hc
om e s ons ite two tim e s pe r m onth to hau laway m e d ic
alwas te . T he re we re no re porte d iss u e s with this
s e rvic
e.
Ins pe c
tion ofthe infirm ary, u rge nt c
are /e m e rge nc
y room , d e ntalc
linic
, s ic
kc
allare as in the m e d ic
al
d e partm e nt and c
e ll hou s e s and e m e rge nc
y re s pons e bags ve rified the pre s e nc
e of pe rs onal
prote c
tive e qu ipm e nt. P u nc
tu re proofc
ontaine rs forthe d ispos alofs harps are in u s e in allm e d ic
al
are as and are appropriate ly plac
e d in the m e d ic
alwas te c
ontaine rs whe n fu ll.
Inm ate s as s igne d as porte rs in the H e althC are U nit and who pe rform janitoriald u ties m ay or
m ay not have re c
e ive d any trainingas to appropriate c
le aningand s anitation m e thod s . T he y are
re qu ire d to watc
hablood -borne pathoge n e d u c
ationalvid e o and are s u pe rvise d by bothnu rs ing
and s e c
u rity s taff.
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 28
27
R e portable ST Is are pic

ke d -u pand re porte d by U IC .
T he re are two ne gative air re s piratory isolation room s loc
ate d in the infirm ary. B oth visu aland
au d ible alarm s ind ic
ate whe n ne gative air has be e n los t. A d d itionally, nu rs ings taff c
ond u c
t a
ne gative airflow tiss u e te st d aily whe n the room s are oc
c
u pied and we e kly ifnot.
A ll m attre s s e s on the infirm ary be d s are plas ticc
oate d and are c
le ane d and s anitize d be twe e n
patients and as ne e d e d .
W he n re qu ire d , the infe c
tion c
ontrolnu rs e inte rfac
e s withthe C ou nty D e partm e nt ofP u blicH e alth
and the Illinois D e partm e nt ofP u blicH e alth(ID P H ). T he nu rs e m onitors , c
om ple te s and s u bm its
to ID P H allre portable c
as e s . Skin infe c
tions and boils are aggre s s ive ly m onitore d , c
u ltu re d and
tre ate d . H e alth C are U nit nu rs ings taff c
ond u c
t m onthly s afe ty and s anitation ins pe c
tions in the
d ietary d e partm e nt and pe rform pre -as s ignm e nt food hand le re xam inations fors taffand inm ate s
to work in the d ietary d e partm e nt. A tou rofthe he althc
are u nit, inc
lu d ingthe infirm ary, ve rified
pe rs onalprote c
tive e qu ipm e nt (P P E)available to staffin allare as as ne e d e d . A d d itionally, P P E is
inc
lu d e d in the e m e rge nc
y re s pons e bags and in the c
e llhou s e s ic
kc
allroom s . P u nc
tu re proof
c
ontaine rs forthe d ispos alofs yringe s /ne e d le s and othe rs harpobje c
ts are in u s e in allare as ofthe
he alth c
are u nit as ne e d e d and in the c
e ll hou s e s ic
kc
all room s . T he fac
ility u s e s a national
c
om m e rc
ialwas te d ispos alc
om pany ford ispos ingofm e d ic
alwas te . Ins titu tionals taffis traine d in
c
om m u nic
able d ise as e s and blood -borne pathoge ns .
InmatesInterviews
Five ins u lin d e pe nd e nt inm ate s we re inte rviewe d . A ll five had be e n d iagnos e d s e ve ral ye ars
pre viou s ly, and all five we re knowle d ge able re gard ing the ir c
hronicd ise as e . A ll five we re
knowle d ge able re gard ingthe s ignific
anc
e ofthe ir he m oglobin A 1cblood le ve l. Fou r ofthe five
kne w the re s u lts ofthe irm os t re c
e nt he m oglobin A 1cblood le ve l. A llfive re porte d be inge valu ate d
by the phys ic
ian e ve ry 3-4m onths and havingthe ability to pe rform blood glu c
os e m onitoringprior
to the ad m inistration ofins u lin. A llfive we re ofthe opinion that the phys ic
ian re s pons ible forthe ir
d iabe ticc
are d oe s agood job.
A llfive
1.
2.
3.
patients voic
e d the followingiss u e s :
V e ry little e d u c
ationallite ratu re provide d /available
D iffic
u lty obtainingm e d ic
ation whe n firs t ord e re d and s om e tim e s withre fills
D iffic
u lty re c
e ivings hoe s ord e re d by the phys ic
ian be c
au s e the y are d e nied by the m e d ic
al
ve nd or
4. N o pod iatry c
are
5. N o on-s ite d ietic
ian
6. W he n e valu ate d by an off-s ite s pe c
ialist, the re is d iffic
u lty ge ttingbac
k to s e e the s pe c
ialist
and the ins titu tionalm e d ic
alve nd ord oe s not follow the s u gge s tions /ord e rs ofthe s pe c
ialist
7. Se c
u rity s taffnot followingphys ic
ian ord e rs , i.e ., not allowingplas ticbas ins forfoot soaks
8. B e ingc
u ffe d from be hind too tightly and fortoo long
9. B re akfas t startingbe twe e n 1:00and 2:00a.m .;lu nc
hs tartingat 9:00a.m .
10. Som e tim e s re c
e ive ins u lin priorto e atingand s om e tim e s afte re ating.
Dental Program
Executive Summary
O n M ay 21 and 22, 2014, ac
om pre he ns ive re view of the d e ntalprogram at State ville C C was
c
om ple te d withthe followingobs e rvations and find ings.
T he c
linicits e lf is rathe r large and we lle qu ippe d . C abine try and c
ou nte rtops are old , worn and
d am age d , m akingprope rd isinfe c
tion alm os t im pos s ible . It is tim e forre plac
e m e nt. A lthou ghthe
s taffingle ve lfor the provide rs is ad e qu ate , the lone d e ntalas s istant is ove rworke d and ofte n not
available to as s ist at c
hairs id e . A s e c
ond d e ntalas s istant s hou ld s e riou s ly be c
ons id e re d .
A m ajorare aofc
onc
e rn was that c
om pre he ns ive c
are was provide d withou t ac
om pre he ns ive intra
and e xtra-oral e xam ination and we ll-d e ve lope d tre atm e nt plan. A d oc
u m e nte d s oft tiss u e
e xam ination was not provide d nor was pe riod ontal as s e s s m e nt part of the tre atm e nt proc
ess.
A ppropriate rad iographs we re not always available and provision ofhygiene c
are and prophylaxis
was inc
ons iste nt. O ralhygiene ins tru c
tions we re s e ld om d oc
u m e nte d .
A nothe r are a of c
onc
e rn was d e ntal e xtrac
tions . A ll d e ntal tre atm e nt s hou ld proc
e e d from a
d oc
u m e nte d d iagnos is. T he re as on fore xtrac
tions s hou ld be part ofthe re c
ord e ntry. T his was ofte n
not the c
as e . A ls o, proper d iagnos ticrad iographs we re not always pre s e nt. T his is a s e riou s
om iss ion. A ntibiotic
s we re ofte n pre s c
ribe d prophylac
tic
ally afte re xtrac
tions withno d iagnos is, or
ind ic
ation why the re we re provide d . T his is not astand ard ofc
are .
P artiald e ntu re s s hou ld be c
ons tru c
te d as afinals te p in the s e qu e nc
e ofc
are d e live ry inc
lu d e d in
the c
om pre he ns ive c
are proc
e s s . A re c
ord re view re ve ale d that all partial d e ntu re s proc
eed ed
withou t ac
om pre he ns ive e xam ination and tre atm e nt plan. P e riod ontalas s e s s m e nt and tre atm e nt
was not provide d . O ralhygiene ins tru c
tions we re s e ld om inc
lu d e d . It was alm os t im pos s ible to
d e m ons trate that allfillings and e xtrac
tions we re c
om ple te d priorto im pre s s ions . P e riod ontalhe alth
was ne ve rd oc
u m e nte d .
A t State ville C C , s ic
kc
allis ac
c
e s s e d throu ghthe inm ate re qu e s t form . T he re was no re altriage
s ys te m in plac
e to e valu ate u rge nt c
are ne e d s , i.e ., pain and s we lling. Inm ate s with u rge nt c
are
c
om plaints from the re qu e s t form ofte n took s ix to s e ve n d ays to be s e e n by the d e ntist or othe r
appropriate he althc
are provid e r. T he s e inm ate s s hou ld be s e e n within 24-48 hou rs from the d ate
ofthe re qu e s t form .
In none ofthe re c
ord s re viewe d was the SO A P form at be ingu s e d . T re atm e nt was provide d with
little inform ation or d etailpre c
e d ingit. R e c
ord entries d id not inc
lu d e c
linic
al obs e rvations or
d iagnos is to ju s tify tre atm e nt.
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 29
A we ll-d e ve lope d P olic

y and P roc
e d u ral M anu al ins u re s that a d e ntal program ad d re s s e s all
e s s e ntialare as and is ru n withc
ontinu ity. T he P olic
y and P rotoc
olm anu alat State ville C C only
ad d re s s e d d e ntalpe rs onne land the ird u ties and re s pons ibilities . T his is not at allad e qu ate . Is s u e s
su c
has ac
c
e s s to c
are, d e ntals e rvic
e s , provision ofc
are , c
linic
alm anage m e nt, infe c
tion c
ontrol,
e tc
. we re not inc
lu d e d at all.
Faile d appointm e nts we re are alproble m at State ville C C . A rate as highas 40% was fou nd . T his
is an u nac
c
e ptably high pe rc
e ntage and re fle c
ts are ald iffic
u lty in ge ttinginm ate s to the d e ntal
c
linicfor appointm e nts . T his re s u lts in d e laye d and inc
ons iste nt tre atm e nt. T he proble m is
c
om pe ns ate d fors om e what by ove rs c
he d u ling, bu t this is not an ac
c
e ptable , long-te rm s olu tion.
M e d ic
al c
ond itions that re qu ire pre c
au tions and c
ons u ltation with m e d ic
al s taff prior to d e ntal
tre atm e nt s hou ld be we lld oc
u m e nte d in the he alth history s e c
ord and re d
flagge d to bringthe m to the im m e d iate atte ntion ofthe provide r. T he pre c
au tions take n s hou ld
als o be we lld oc
u m e nte d in the re c
ord e ntry. A ntic
oagu lant the rapy is agood be llwe the rc
ond ition
to trac
k the above . In thre e ofthe s ix re c
ord s re viewe d , no he althhistory was d oc
u m e nte d at allon
the d e ntalre c
ord . N one ofthe re c
ord s we re re d flagge d forantic
oagu lant the rapy orany c
ond ition
re qu iringpre c
au tions .
B lood pre s s u re s s hou ld , at the le as t, be take n on patients with ahistory of hype rte ns ion. W he n
as ke d , the c
linic
ians ind ic
ate d that the y d o not rou tine ly take blood pre s s u re s on the s e patients .
A lthou ghd e ntalc
ontribu te s to the C ontinu ingQ u ality Im prove m e nt program at State ville C C , it
s hou ld invigorate and e xpand the C Q I proc
e s s to ad d re s s the we akne s s e s ou tline d in this re port.
Staffing and Credentialing

State ville C C has ad e ntals taffofone fu ll-tim e d e ntist, one 20hou rpart-tim e d e ntist, two fu ll-tim e
as s istants , and afu ll-tim e hygienist. T his s hou ld be ad e qu ate to provide m e aningfu ld e ntals e rvic
es
forState ville
s 2000inm ate s . D r. M itc
he llis e m ploye d by the ID O C and allthe re s t ofthe s taffare
c
ontrac
te d by W e xford H e althSe rvic
es.
C P R trainingis c
u rre nt on alls taff, allne c
e s s ary lic
e ns ingis on file , and D E A nu m be rs are on file
for the d e ntists . T he nu m be r of d e ntists and hygienists is ad e qu ate to m e e t the ne e d s of this
ins titu tion. T he lone as s istant is ove rworke d in ac
linicwiththis m any d e ntists . O n the whole , this
is as trongte am that works we lltogethe rto c
re ate ave ry bu s y and s m oothru nningc
linic
.
Recommendations:
1. Se riou s c
ons id e ration s hou ld be give n to hiringas e c
ond d e ntalas s istant. T he lone as s istant
has too m any d u ties to pe rform and the d e ntists are ofte n le ft workingwithou t an as s istant.
T his is profe s s ionally ve ry u nre ward ingand c
an pre s e nt risks to the patient. A lls u rge ries
s hou ld be pe rform e d only withan as s istant.
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 30
Facility and Equipment

T he c
linicc
ons ists of fou r c
hairs and u nits in as pac
iou s s ingle room are a. O ne of the u nits is
d e d ic
ate d to hygiene c
are . T he d e ntalu nits we re rathe r ne w and in good c
ond ition. T he c
hairs
we re ove r20ye ars old bu t we re not torn orove rly worn, and fu nc
tione d we ll. C abine try was ve ry
old and worn. C ou nte rtops we re broke n, c
orrod e d and bad ly wate rd am age d in one ofthe c
orne rs .
T he re was e xtre m e wate rd am age in the c
abine t u nd e rthe s ink. W ork s u rfac
e s we re bad ly pitte d
and c
ate re d from u s e . P le xiglas was plac
e d ove rthe s e s u rfac
e s to provid e as m oothwork s u rfac
e
c
apable ofd isinfe c
tion. T he x-ray u nit is in good re pair and works we ll. T he au toc
lave is rathe r
ne w and fu nc
tions we ll. T he c
om pre s s or is in good re pair. T he ins tru m e ntation is ad e qu ate in
qu antity and qu ality. T he hand piec
e s are old e rbu t we llm aintaine d and re paire d whe n ne c
e s s ary.
T he u ltra-s onicu nit was not workingat the tim e ofm y visit. I was told that are qu e s t for re pair
had be e n s u bm itte d .
A gain, the c
linicits e lfc
ons iste d offou rc
hairs in as pac
iou s work are a. Fre e m ove m e nt arou nd e ac
h
u nit was ac
c
e ptable P rovide rs and as s istants had ad e qu ate room to work, and none ofthe c
hairs
inte rfe re d withe ac
hothe r. T he re was as e parate large s te rilization and laboratory are aofad e qu ate
s ize . It had alarge work s u rfac
e and alarge s ink to ac
c
om m od ate prope r infe c
tion c
ontroland
s te rilization. Laboratory e qu ipm e nt was in as e parate are aofthis s pac
e and d id not inte rfe re with
s te rilization. T he s taffhad as e parate rathe rs m allroom foroffic
e s pac
e.
Recommendations:
1. R e plac
e the c
abine try and c
ou nte rtops as the y are ve ry old , worn and irre ve rs ibly
d am age d . P rope rinfe c
tion c
ontrolis alm os t im pos s ible on the s e s u rfac
es.
Sanitation, Safety and Sterilization

W e obs e rve d the s anitation and s te rilization te c
hniqu e s and proc
e d u re s . Su rfac
e d isinfe c
tion was
pe rform e d be twe e n e ac
hpatient and was thorou ghand ad e qu ate . P rope rd isinfe c
tants we re be ing
u s e d . P rote c
tive c
ove rs we re u tilize d on s om e of the s u rfac
e s . U nit re c
yc
lingwas thorou gh and
ad e qu ate . A llin all, the c
linicwas ne at, c
le an and ord erly.
A n e xam ination ofins tru m e nts in the c
abine ts re ve als that allwe re prope rly bagge d and s te rilize d
and s tore d . N o ins tru m e nts we re m aintaine d in bu lk. A llhand piec
e s we re s te rilize d and in bags.
T he s te rilization proc
e d u re s the m s e lve s we re ad e qu ate and prope r. Flow from d irty to c
le an to
s te rilize d was im prope r, as baggingofins tru m e nts was d one in front ofthe u ltra-s onicu nit. C le ane d
ins tru m e nts we re pas s e d bac
k ove rthe d irty are a. T he u ltra-s onicwas not fu nc
tioningat the tim e
ofm y visit.
T he re was not abiohaz ard labe lpos te d in the s terilization are a. Safe ty glas s e s we re not always
worn by patients . E ye prote c
tion is always ne c
e s s ary, forpatient and provide r. I als o obs e rve d that
no warnings ign was pos te d whe re x-rays we re be ingtake n to warn pre gnant fe m ale s ofpos s ible
rad iation haz ard s .
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 31
Review Autoclave Log

A re view ofs pore te s tinglogs re ve ale d that aM axi-te s tin offic
e biologic
alind ic
ators ys te m was
in u s e . T he inc
u bator was m aintaine d in the s te rilization are a. T he re s u lts we re logge d we e kly.
T he re was agapin logge d re s u lts from the las t we e k ofJanu ary to the firs t we e k in A prilwithno
re ale xplanation provide d . I was as s u re d that the tes tingwas d one d u ringthis pe riod . It is e s s e ntial
that the s e logs be ac
c
u rate ly m aintaine d ove ralongpe riod oftim e .
Recommendations:
1. T hat the s te rilization s pore te s ting log be ac
c
u rate ly m aintaine d and ke pt on re c
ord
ind e finite ly.
2. T hat s afe ty glas s e s be provide d to patients while the y are be ingtre ate d .
3. T hat abiohaz ard warnings ign be pos te d in the s te rilization are a.
4. A warnings ign be poste d in the x-ray are ato warn ofrad iation haz ard s , e s pe c
ially pre gnant
fe m ale s .
Comprehensive Care
W e re viewe d 10d e ntalre c
ord s ofinm ate s in ac
tive tre atm e nt c
las s ified as C ate gory 3patients .
O ne ofthe m os t bas icand e s s e ntials tand ard s ofc
are in d e ntistry is that allrou tine c
are proc
eed
from athorou gh, we ll-d oc
u m e nte d intraand e xtra-orale xam ination and awe ll-d e ve lope d tre atm e nt
plan, to inc
lu d e allne c
e s s ary d iagnos ticx-rays . A re view of10re c
ord s re ve ale d no c
om pre he ns ive
e xam ination was pe rform e d in thre e ofthe re c
ord s and ve ry m inim ale xam inations in thre e othe rs .
In only fou r re c
ord s d id a m e aningfu l c
om pre he ns ive e xam ination pre c
e d e rou tine c
are . N o
e xam ination ofs oft tiss u e s orpe riod ontalas s e s s m e nt was part ofthe tre atm e nt proc
e s s . H ygiene
c
are and prophylaxis was inc
ons iste nt, provide d in s ix ofthe 10patient re c
ord s . A fu rthe rre view
s howe d that bite wingrad iographs we re part of the tre atm e nt proc
e s s in e ight of the 10 re c
ord s .
R e s torations we re , in two of the 10 patients , provid e d from the inform ation from the panore x
rad iograph. T his rad iographis not d iagnos ticforc
aries . A pe riod ontalas s e s s m e nt was not d one in
any ofthe re c
ord s . Fu rthe r, oralhygiene ins tru c
tions we re not always d oc
u m e nte d in the d e ntal
re c
ord as part ofthe tre atm e nt proc
ess.
Recommendations:
1. C om pre he ns ive rou tine c
are be provid e d only from awe ll-d e ve lope d and d oc
u m e nte d
tre atm e nt plan.
2. T he tre atm e nt plan be d e ve lope d from athorou gh, we ll-d oc
u m e nte d intraand e xtra-oral
e xam ination, to inc
lu d e a pe riod ontal as s e s s m e nt and d e taile d e xam ination of all s oft
tiss u e s .
3. In allc
as e s , that appropriate bite wingorpe ri-apic
alx-rays be take n to d iagnos e c
aries .
4. H ygiene c
are be provide d as part ofthe tre atm e nt proc
ess.
5. T hat c
are be provide d s e qu e ntially, be ginning with hygiene s e rvic
e s and d e ntal
prophylaxis.
6. T hat oralhygiene ins tru c
tions be provide d and d oc
u m e nte d .
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 32
Dental Screening
A lthou ghState ville C C is not are c
e ption and c
las s ific
ation c
e nte r, I re viewe d 10 inm ate d e ntal
re c
ord s that we re re c
e ive d from the re c
e ption c
e nte rs within the pas t 60 d ays to d ete rm ine if:1)
sc
re e ningwas pe rform e d at the re c
e ption c
e nte rand 2)apanoram icx-ray was take n, to ins u re the
re c
e ption and c
las s ific
ation polic
ies as s tate d in A d m inistrative D ire c
tive 04.03.102, s e c
tion F. 2,
are be ingm e t forthe ID O C .
Recommendations: N one . A llre c
ord s re viewe d we re in c
om plianc
e.
Extractions
ord s ofd e ntals u rgic
alinm ate s to d e term ine if:
1. R e c
e nt pre -ope rative rad iographs re fle c
tingthe c
u rre nt c
ond ition oftoothe xtrac
te d . X -rays
m u s t be d iagnos ticvalu e s howingapic
e s ofte e th.
2. R e as on fore xtrac
tion is d oc
u m e nte d .
3. C ons e nt Form is u s e d and s igne d by the patient.
O ne ofthe prim ary te ne ts in d e ntistry is that alld e ntaltre atm e nt proc
e e d s from awe ll-d oc
u m e nte d
d iagnos is. In fou rofthe 10re c
ord s re viewe d , the re as on forthe e xtrac
tion was not d oc
u m e nte d . In
two ofthe re c
ord s , aprope rd iagnos ticx-ray was not pre s e nt. T his is as e riou s om iss ion. R e c
ord
e ntries are ofte n ve ry d iffic
u lt to follow. T re atm e nt at tim e s s e e m e d d isjointe d and lac
kingin
c
ontinu ity. T he tim e be twe e n appointm e nts c
an be longd u e to re s c
he d u lingas s oc
iate d withfaile d
appointm e nts . A ls o, antibiotic
s we re ofte n give n afte r e xtrac
tions . T he y s e e m e d to be provid e d
prophylac
tic
ally. T his is not an ind ic
ate d s tand ard ofc
are . T he y s hou ld be pre s c
ribe d only whe n
ind ic
ate d by awe ll-e s tablishe d d iagnos is.
Recommendations:
1. A d iagnos is orare ason forthe e xtrac
tion be inc
lu d e d as part ofthe re c
ord e ntry. T his is
be s t ac
c
om plishe d throu ghthe u s e ofthe SO A P note form at, e s pe c
ially fors ic
kc
alle ntries .
It wou ld provide m u c
hd e tailthat is lac
kingin m any d e ntale ntries obs e rve d . It wou ld als o
aid in e s tablishingabe tte rc
ontinu ity ofc
are .
2. P rope rd iagnos ticx-rays be available fore ve ry s u rgic
alproc
e d u re .
3. P re s c
ribe antibiotic
s only as ne c
e s s ary. P re s c
ribingrou tine ly afte r e xtrac
tions is not a
s tand ard ofc
are .
Removable Prosthetics
W e re viewe d d e ntal re c
ord s of five patients having re c
e ive d c
om ple te d partial d e ntu re s to
d e te rm ine if re s torative proc
e d u re s we re c
om ple te d prior to fabric
ation of partiald e ntu re s (68M E D -12D e ntalSe rvic
e s D . P rovision ofD e ntalC are page 4#5and #9).
R e m ovable partiald e ntu re pros the tic
s s hou ld proc
e e d only afte r allothe r tre atm e nt re c
ord e d on
the tre atm e nt plan is c
om ple te d . C ontinu ity ofc
are is im portant and the pe riod ontal, ope rative and
orals u rge ry ne e d s alls hou ld be ad d re s s e d firs t. In only one ofthe five re c
ord s re viewe d on patients
re c
e iving re m ovable partial d e ntu re s we re oral hygiene ins tru c
tions provid e d . P e riod ontal
as s e s s m e nt was not provide d in any ofthe re c
ord s , and in only one ofthe five
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 33
re c
ord s was a prophylaxis and /or a s c
alingd e bride m e nt provide d . B e c
au s e a c
om pre he ns ive
e xam ination was part ofonly two re c
ord s and treatm e nt plans we re ve ry inc
om ple te , it is alm os t
im pos s ible to as c
e rtain ifallne c
e s s ary c
are , inc
lu d ingope rative and /ororals u rge ry tre atm e nt, is
c
om ple te d priorto fabric
ation ofre m ovable partiald e ntu re s .
Recommendations:
1. A c
om pre he ns ive e xam ination and we ll-d e ve lope d and d oc
u m e nte d tre atm e nt plan,
inc
lu d ingbite wingand /orpe riapic
alrad iographs and pe riod ontalas s e s s m e nt, proc
e e d all
c
om pre he ns ive d e ntalc
are , inc
lu d ingre m ovable prosthod ontic
s.
2. T hat pe riod ontalas s e s s m e nt and tre atm e nt be part of the tre atm e nt proc
e s s and that the
pe riod ontiu m be s table be fore proc
e e d ingwithim pre s s ions .
3. T hat all ope rative d e ntistry and oral s u rge ry as d oc
u m e nte d in the tre atm e nt plan be
c
om ple te d be fore proc
Dental Sick Call

Inm ate s ac
c
e s s s ic
kc
allthrou ghan inm ate re qu e s t form orviaad ire c
tc
allfrom as taffm e m be rif
it is pe rc
e ive d as an e m e rge nc
y. In ad d ition to aR e qu e s t Log that logs inm ate re qu e s t form s ,
the re is an E m e rge nc
y Logm aintaine d whic
htrac
ks patients s e e n as e m e rge nc
y.T he s e inm ate s
are s e e n the s am e d ay as the re qu e s t. For2014thu s far, 12inm ate s we re s e e n as an e m e rge nc
y. A ll
we re toothac
he s , abs c
e s s e s ortrau m a.
T he re is no re altriage s ys te m in plac
are ne e d s (toothac
he s , pain, s we lling)
from the re qu e s t form s . O fthe inm ate s plac
e d in the R e qu e s t Log, the ave rage wait forappointm e nt
was abou t 12d ays . T his is forallre qu e s t form s . O fthe re qu e s ts logge d in as toothac
he s , pain, or
s we lling, the ave rage wait was approxim ate ly s ix to s e ve n d ays . T he s e inm ate s s hou ld be s e e n
within 24-48hou rs .
In none ofthe d e ntalre c
ord s re viewe d was the SO A P form at be ingu s e d . A s are s u lt, tre atm e nt was
u s u ally provide d withlittle inform ation ord etailpre c
e d ingit. Sic
kc
allre c
ord e ntries ofte n d id not
inc
lu d e c
linic
al obs e rvations or d iagnos is to ju s tify provid e d tre atm e nt. Little c
ontinu ity was
e s tablishe d . T he u s e of the SO A P form at wou ld ins u re that awe ll-d e ve lope d d iagnos is wou ld
pre c
e d e alltre atm e nt. In allre c
ord s , the im m e d iate c
om plaint was ad d re s s e d . O nly e m e rge nc
yc
are
was be ingprovid e d .
Recommendations:
1. Im ple m e nt the u s e ofthe SO A P form at fors ic
kc
alle ntries . It willas s u re that the inm ate
s
c
hief c
om plaint is re c
ord e d and ad d re s s e d and a thorou gh foc
u s e d e xam ination and
d iagnos is pre c
e d e s alltre atm e nt.
2. D e ve lopatriage s ys te m that ins u re s that inm ate s withu rge nt c
are c
om plaints are s e e n in a
m ore tim e ly m anne r, 24to 48hou rs .
Treatment Provision
T he re is no re altriage s ys te m in plac
e . T he only triage s ys te m at this ins titu tion is from the re qu e s t
form its e lf. A llre qu e s t form s are logge d into aR e qu e s t Log.O fallofthe re qu e s t
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 34
form s plac
e in this log, the ave rage wait forappointm e nt was abou t 12d ays . O fallofthe re qu e s ts
form s withc
om plaint ofpain, toothac
he , ors we lling, the ave rage wait was s ix to s e ve n d ays . T his
is an u nd u ly am ou nt of tim e . O f all the re qu e s t form s , 15% are u rge nt c
are c
om plaints (pain,
toothac
he s , s we lling). T his is only abou t one pe rd ay. T he s e inm ate s s hou ld be s e e n within 24-48
hou rs .
Inm ate s c
an s e e k u rge nt c
are viathe inm ate re qu e s t form or, if the y fe e lthe y ne e d to be s e e n
im m e d iate ly, by c
ontac
tingState ville C C s taff, who willthe n c
allthe d e ntalc
linicwiththe inm ate
s
c
om plaint. T he inm ate is s e e n that d ay fore valu ation. R e qu e s t form c
om plaints from inm ate s with
u rge nt c
are ne e d s (c
om plaint ofpain ors we lling)are not s e e n u ntils ix to s e ve n d ays late r. M idle ve lprac
titione rs are available at alltim e s to ad d re s s u rge nt d e ntalc
om plaints . T he y c
an provid e
ove r-the -c
ou nte rpain m e d ic
ation orc
allm e d ic
al/d e ntals taffifthe y fe e lm ore is ne e d e d . H owe ve r,
this is s e ld om the c
as e .
Inm ate s who s u bm it re qu e s t form s forrou tine c
are are s e e n and e valu ate d in abou t 14d ays . T he y
are plac
e d s e qu e ntially on awaitinglist. T he s ys te m s e e m s fairand e qu itable .
Recommendations:
1. T hat am e aningfu ltriage s ys te m be e s tablishe d s u c
hthat inm ate s withc
om plaints ofpain
are ide ntified and prioritize d .
2. T hat inm ate s withu rge nt c
are c
om plaints are provid e d tim e ly and appropriate e valu ation
and c
are . Six to s e ve n d ays is not ac
c
e ptable . Se e ingthat one pe rd ay u rge nt c
are c
om plaint
s hou ld be ve ry d oable .
Orientation Handbook
A re view ofthe O ffe nd e rO rientation M anu alforState ville C C and the N R C re ve ale d that d e ntal
was we llre pre s e nte d and the ins tru c
tions as it re late s to ac
c
e s s to c
are is ad e qu ate .
Policies and Procedures

A we ll-d e ve lope d P olic
y and P roc
e d u re s m anu alins u re s ad e ntalprogram that is we llu nd e rs tood
and ru n withc
ontinu ity. It ad d re s s e s allas pe c
ts ofthe d e ntalprogram to provid e c
ons iste nc
y of
c
are and m anage m e nt. T he polic
y and protoc
olm anu alfor the d e ntalprogram at State ville C C
ad d re s s e s only d e ntalpe rs onne land the ird u ties and re s pons ibilities . It only s tate s that the d e ntal
program is re s pons ible to provid e d e ntalc
are to the offe nd e rpopu lation. N o s pe c
ific
s we re provide d
on ac
c
e s s to c
are , provision ofc
are , c
linicm anage m e nt, d e ntals e rvic
e s provide d , infe c
tion c
ontrol,
e tc
. T he d e ntald ire c
tors aid that this was d e ve lope d by ad m inistration who thou ght itwas s u ffic
ient.
Recommendations:
1. D e ve lopathorou ghand d e taile d P olicy and P roc
e d u re s m anu althat d e s c
ribe s and gu id e s all
as pe c
ts ofthe d e ntalprogram at State ville C C . It s hou ld inc
lu d e allofthe are as ind ic
ate d
above .
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 35
Failed Appointments
A re view ofm onthly re ports and d aily work s he e ts re ve ale d afaile d appointm e nt rate that ave rage d
40% . T his is ave ry highpe rc
ts as e riou s proble m in ge ttinginm ate s to the c
linic
for the ir appointm e nt. I was told that the y s hare d m y c
onc
e rn and we re fru s trate d at the lac
k of
su c
c
e s s in ad d re s s ingthis proble m . I was told that the re as ons forfaile d appointm e nts inc
lu d e d the
following:
Inm ate s
Inm ate s
Inm ate s
Inm ate s
Inm ate s
d o not get the irpas s e s

go to otherprogram s orappointm e nts
go to re c
re ation
go to c
om m iss ary
in loc
kd own
T he pe rc
e ntage d oe s re fle c
t loc
kd own d ays , whic
h ave rage abou t two am onth. T he proble m is
c
om pe ns ate d forby ove rs c
he d u linge ve ry d ay. A s s u c
h, alarge nu m be rofinm ate s are s e e n e ve ry
d ay, and alarge nu m be rals o failto s how.
I d isc
u s s e d this iss u e with the ad m inistrative s taff, inc
lu d ingthe W ard e n, and the y s hare d the
c
onc
e rn and fru s tration ofthe d e ntals taffand want to he lpthe m ad d re s s the proble m .
Recommendations:
1. W ork withthe ins titu tion ad m inistration to d e ve lop and im ple m e nt s trate gies to ad d re s s
this proble m .
2. U tilize avigorou s C ontinu ingQ u ality Im prove m e nt proc
e s s to ad d re s s this proble m . U s e
the s e find ingto im ple m e nt proc
e d u re s to c
ontinu ally im prove this high rate of faile d
appointm e nts .
Medically Compromised Patients

A re view ofs ix d e ntalre c
ord s ofinm ate s who we re on antic
oagu lant the rapy re ve ale d that thre e of
the re c
ord s had no he alth history d oc
u m e ntation as part of the d e ntalre c
ord . In the othe r thre e
re c
ord s , it was d oc
u m e nte d and re d flagge d . In allc
as e s ofprovide d d e ntalc
are to the s e patients ,
m e d ic
als taffwas c
ons u lte d and antic
oagu lant the rapy pre c
au tions we re ad d re s s e d and followe d .
W he n as ke d , the c
linic
ians ind ic
ate d that the y d o not rou tine ly take blood pre s s u re s on patients
withahistory ofhype rte ns ion.
Recommendations:
1. T hat the m e d ic
alhistory s e c
ord be ke pt u pto d ate and that m e d ic
al
c
ond itions that re qu ire s pe c
ialpre c
au tions be re d flagge d to c
atc
hthe im m e d iate atte ntion
ofthe provide r.
2. T hat blood pre s s u re re ad ings be rou tine ly take n on patients withahistory ofhype rte ns ion,
e s pe c
ially priorto any s u rgic
alproc
e d u re .
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 36
Specialists
D r. Fre d e ric
k C raig, oral s u rge on, is available on an as -ne e d e d bas is, u s u ally onc
e a m onth,
s om e tim e s twic
e . D r. C raigis als o u s e d by s e ve ralothe r ID O C ins titu tions fororals u rge ry. T he
d e ntalprogram als o u tilize s Joliet O ralSu rge ons , aloc
alorals u rge ry grou p, form ore d iffic
u lt c
as e s
and for ge ne ralane s the s ia. P athology s e rvic
e s are the s am e as for m e d ic
alpathology. T he y give
the s pe c
im e n to the appropriate m e d ic
alpe rs on for proc
e s s ing. A llrad iographs we re c
u rre nt and
allre c
ord e ntries we re ad e qu ate . T he N R C u tilize s the s e s e rvic
e s throu ghState ville C C .
Dental CQI
T he d e ntalprogram c
ontribu tion to m onthly C Q I inc
lu d e s athorou ghd oc
u m e ntation ofd e ntal
s tatistic
s and prod u c
tivity nu m be rs . T he re is an ongoingqu ality im prove m e nt re port forthe d e ntal
program that s e e ks to im prove the ability of s e gre gation inm ate s to ge t to the d e ntalclinicfor
the ir appointm e nts . It is as tu d y that looks at the re as ons why the y are not ge ttingto the clinic.
T he s e find ingm u s t be u s e d to d e ve lopproc
e d u re s to im prove this proble m . C ons id e ration s hou ld
be give n to c
ond u c
t ongoings tu d ies withthe N R C .
Recommendation:
1. B e c
au s e ofthe nu m be rofd e fic
ienc
ies note d in the d e ntalprogram , am ore
program s hou ld be im ple m e nte d to ad d re s s the s e d e fic
ienc
ies . From the
polic
ies and proc
e d u re s s hou ld be e s tablishe d that will c
ontinu ally
d e fic
ienc
ies to d e ve lopastronge rprogram .
2. Inc
lu d e the N R C in this invigorate d C Q I proc
e s s . M any are as ne e d to be
im prove m e nt at that ins titu tion.
vigorou s C Q I
C Q I proc
ess,
c
orre c
t the s e
ad d re s s e d for

T he re have be e n no C Q I m e e tings s inc
eO c
tobe rand no m inu te s we re available s inc
e 7/13/13. T he
m inu te s we we re s hown c
ontaine d no narrative , no analys is ofthe d atapre s e nte d and no s tu d ies .
T his c
an only be c
harac
te rize d as anon-fu nc
tioningqu ality im prove m e nt program . T he he alth
c
are u nit ad m inistratoris to be the Q I c
oord inator, bu t s he has be e n offd u e to m e d ic
alle ave . W ith
re gard to grievanc
e s , the re is no m e d ic
algrievanc
ec
oord inatorat e ithe rState ville orN R C . T he y
d o re port grievanc
e s , bu t d e s pite the fac
t that the nu m be rofgrievanc
e s fore ac
hm onthis s u ppos e d
to be liste d , it appe ars that the re was aye arwithno grievanc
e s . A ls o, the grievanc
e proc
e s s ne ve r
inclu d e s inte rviewingofthe grievant. T his is anon-fu nc
tioningm e d ic
algrievanc
e proc
ess.
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 37
Recommendations
Leadership and Staffing:
1. State ville re qu ire s its own H e althC are U nit A d m inistratorpos ition.
2. State ville re qu ire s its own s taffingalloc
ation s pe c
ific
ally to m e e t the State ville s e rvic
e
d e m and s .
3. O nly traine d prim ary c
are c
linic
ians (Inte rnalM e d ic
ine and Fam ily P rac
tic
e )s hou ld be
provid ingprim ary c
are to this popu lation.
4. P hys ic
ians s hou ld be board c
e rtified in aprim ary c
are field .
5. A llhe althc
are provide rs s hou ld have ac
c
e s s to e le c
tronicm e d ic
alre fe re nc
es.
Clinic Space and Sanitation:
1. D e s ignate d e xam room s s hou ld be m ad e available withappropriate e qu ipm e nt in c
e llhou s e s
B , E and Fto allow s ic
kc
allto oc
c
u rwithre d u c
e d m ove m e nt d e m and s .
Intrasystem Transfer:
1. T he intras ys te m trans fe r proc
e s s ne e d s to be appropriate ly ad d re s s e d to e ffe c
tive ly ins u re
c
ontinu ity ofc
are for patients who e nte r withprior d iagnos e d proble m s . T his s hou ld be
m onitore d by the Q I program .
Sick Call:
1. C u s tod y iss u e s s hou ld not inte rfe re withthe provision oftim e ly he althc
are .
2. T he re s hou ld be no s u c
hthingas ano s how in aprison. P atients m ay re fu s e c
are bu t
s hou ld be re qu ire d to re port to the he alths e rvic
e s are awhe n s c
he d u le d .
Chronic Disease Clinics:
1. P atients s hou ld be s c
he d u le d in ac
c
ord anc
e withthe ird e gre e ofd ise as e c
ontrol, withm ore
fre qu e nt visits whe n d ise as e c
ontrolis poorand le s s fre qu e nt visits forthos e u nd e r good
c
ontrol. T his is as tate wide polic
y iss u e whic
hne e d s to be c
orre c
te d .
2. ForD iabe te s C linic
:
a. M e als s hou ld be s e rve d on apre d ic
table s c
he d u le to fac
ilitate the c
oord ination of
ins u lin ad m inistration withfood c
ons u m ption.
b. T ype 1d iabe tic
s s hou ld have ac
c
e s s to phys iologicins u lin re plac
e m e nt with3-4
inje c
tions pe rd ay ifne e d e d .
3. ForH IV C linic
:
a. P atients withH IV infe c
tion s hou ld be form ally e nrolle d in the c
hronicc
are
program ju s t as patients withothe rd ise as e s are .
b. Fac
ility c
linic
ians s hou ld be providingprim ary c
are to this popu lation. T his wou ld
inc
lu d e ac
tive ly m onitoringthis high-risk popu lationform e d ic
ation c
om plianc
e , s ide
e ffe c
ts, and the prim ary c
are c
om plic
ations re lated to the d ise as e and its tre atm e nt,
su c
has hype rlipide m ia, d iabe te s and c
ard iovas c
u lard ise as e .
c
. T he c
hronicc
are nu rs e s hou ld be d oingm e d ic
ation c
om plianc
e c
he c
ks withH IV
patients at le as t m onthly.
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 38
Urgent/Emergent Services:
1. T he u rge nt/e m e rge nt program re qu ire s re view and fe e d bac
k bothwithre gard to tim e line s s ,
appropriate ne s s and c
ontinu ity ofc
are . T his s hou ld be d one by c
linic
alle ad e rs hipand the
Q I program .
Scheduled Offsite Services-Consultations/Procedures:
1. Sc
e s ne e d to be im prove d withre gard to tim e line s s ofac
c
e s s to the s e
s e rvic
e s as we llas follow u pafte rthe s e rvic
e is provide d .
2. T he re s hou ld be a re liable m e thod of c
om m u nic
ation be twe e n the s c
he d u le r and the
c
linic
ians to e ns u re that patients who re qu ire s pe c
ialty c
ons u ltation are s c
he d u le d
c
om m e ns u rate withthe u rge nc
y ofthe irne e d .
Infirmary:
1. P atients s hou ld be s e e n tim e ly ac
c
ord ingto polic
y re qu ire m e nts while in the infirm ary.
2. Ifc
linic
ians c
hoos e not to tre at patients ac
c
ord ingto c
u rre ntly ac
c
e pte d re c
om m e nd ations
and gu ide line s , the rationale forthe s e d e c
isions s hou ld be artic
u late d in the he althre c
ord .
Continuous Quality Improvement:
1. T he C Q I program , whic
hs hou ld have id e ntified m any ofthe s e program m aticd e fic
ienc
ies
m u s t be re invigorate d with le ad e rs hip that has had appropriate trainingwith re gard to
qu ality im prove m e nt philos ophy and m e thod ology.
2. T he re s hou ld be profe s s ionalpe rform anc
e re views withfe e d bac
k, bothforthe ad vanc
ed
le ve lc
linic
ians and nu rs e s withre gard to the s ic
kc
allproc
ess.
3. T he le ad e rs hipofthe c
ontinu ou s qu ality im prove m e nt program m u s t be re traine d re gard ing
qu ality im prove m e nt philos ophy and m e thod ology, alongwith s tu d y d e s ign and d ata
c
olle c
tion.
4. T his trainings hou ld inc
lu d e how to s tu d y ou tliers in ord e rto d e ve loptargete d im prove m e nt
s trate gies .
Febru ary 2014
S tatevill
e C orrec ti
onalFac ili
ty
P age 39
Appendix A Patient ID Numbers

Patient Number
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
Provider Sick Call:
Patient Number
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
Offsite Service/Emergency:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
Name
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
Scheduled Offsite Service:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Chronic Disease Management:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
Febru ary 2014
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
S tatevill
e C orrec ti
onalFac ili
ty
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P age 40
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
P atient #11
P atient #12
P atient #13
P atient #14
P atient #15
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Nurse Sick Call:

Patient Number
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
Infirmary:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
Febru ary 2014
Name
[redacted]
[redacted]
[redacted]
[redacted]
S tatevill
e C orrec ti
onalFac ili
ty
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
P age 41
Northern Reception Center

(NRC) Report
January 21-23, 2014

Ron Shansky, MD
Karen Saylor, MD
Larry Hewitt, RN
Karl Meyer, DDS
Contents
Overview....................................................................................................................................3
Executive Summary ..................................................................................................................3
Findings .....................................................................................................................................5
Le ad e rs hipand Staffing...........................................................................................................5
C linicSpac
e and Sanitation .....................................................................................................7
R ec
e ption P roc
e s s ing...............................................................................................................8
Intras ys te m T rans fe r..............................................................................................................11
M e d ic
alR e c
ord s ....................................................................................................................11
N u rs ingSic
k C all...................................................................................................................12
P rovid e rSic
k C all..................................................................................................................13
C hronicD ise as e M anage m e nt................................................................................................14
P harm ac
y/M e d ic
ation A d m inistration................................................................................... 18
Laboratory .............................................................................................................................19
U rge nt/E m e rge nt C are ...........................................................................................................19
Sc
e d u re s ............................................................20
Infirm ary ...............................................................................................................................21
D e ntalP rogram ......................................................................................................................22
C ontinu ou s Q u ality Im prove m e nt ..........................................................................................33
Recommendations ...................................................................................................................34
Appendix A Patient ID Numbers.........................................................................................36
Janu ary 2014
N orthern Rec epti

on C enter
P age 2
Overview
O n Janu ary 20, 2014, we visite d the N orthe rn R e c
e ption C e nte r(N R C )in Joliet, IL. T his was the
firs t s ite visit to N R C and this re port d e s c
ribe s ou r find ings and re c
om m e nd ations . D u ringthis
visit, we :
al
als e rvic
e s are a
are s taff
u m e nts
Inte rviewe d inm ate s
T he N orthe rn R e c
e ption C e nte r(N R C )ope ne d in 2004and hou s e s approxim ate ly 2300 inm ate s ,
withthe ave rage le ngthofs tay be ing3-4 we e ks . It was re porte d , howe ve r, that 587 inm ate s on
writ s tatu s have re m aine d in the fac
ility in e xc
e s s of 60 d ays . T he fac
ility re c
e ive s 500-600
inm ate s pe rwe e k, withC ook C ou nty Jail, C hic
ago, IL, be ingthe large s t c
ontribu tor.
T he re is as hare d W ard e n, H e althC are U nit A d m inistrator(H C U A )and nu rs ings taffbe twe e n the
N R C and State ville C orre c
tionalC e nte r(State ville ), whic
his loc
ate d im m e d iate ly ad jac
e nt to the
N R C . It was re porte d that aH C U A pos ition m ay be ad d e d s pe c
ific
ally forthe N R C . T he N R C has
a d e d ic
ate d M e d ic
al D ire c
tor, D ire c
tor of N u rs ing, M e d ic
al R e c
ord s D e partm e nt D ire c
tor,
s u pe rvisingnu rs e and d e ntals taff. T he s e are ac
om bination of s tate and ve nd or pos itions , with
s taffbe ings hare d be twe e n the two fac
ilities bas e d on ne e d at any give n tim e . It was re porte d that
W e xford is provid ingad d itionalc
linic
ian hou rs on the we e ke nd s to fac
ilitate the c
om ple tion of
s ic
kc
allfor the m inim u m -s e c
u rity u nit (M SU )and the c
om ple tion ofre c
e ption intake phys ic
al
e xam inations . A m ore c
om ple te re view ofs taffingwillbe provide d in the ac
c
om panyingState ville
C orre c
tionalC e nte rre port.
C om pre he ns ive m e d ic
al s e rvic
e s are provid e d throu gh a c
ontrac
tu al agre e m e nt be twe e n the
Illinois D e partm e nt of C orre c
tions (ID O C ) and W e xford H e alth Sou rc
e s (W e xford ) loc
ate d in
P itts bu rg, P A . P harm ac
e u tic
als e rvic
e s are provid e d by B os we llP harm ac
e u tic
als , als o loc
ate d in
P itts bu rg, and laboratory s e rvic
e s are provide d throu gh the U nive rs ity of IllinoisC hic
ago
H os pital.
A pape rm e d ic
alre c
ord c
ontinu e s to be in u s e ;howe ve r, W e xford has id e ntified aprovide rand is
m ovingforward to provide an e le c
tronicm e d ic
alre c
ord (E M R ).
Executive Summary
State ville is a m u lti-m iss ion fac
ility c
om prise d of the N orthe rn R e c
e ption C e nte r (N R C ), a
m axim u m -s e c
u rity m ale u nit (State ville ), and a m inim u m -s e c
u rity u nit (M SU ). T he c
u rre nt
popu lation ofthe e ntire c
om ple x was approxim ate ly 4000inm ate s ;rou ghly 1600in State ville , 280
in M SU and 2200in the R e c
e ption C e nter, whic
hwas d e s igne d to hou s e 1975. T his re port d e s c
ribe s
ou rfind ings at N R C and M SU . T he ave rage le ngthofstay in the R e c
e ption C e nterwas
Janu ary 2014
N orthern Rec epti

on C enter
P age 3
approxim ate ly 3-4 we e ks ;howe ve r, m axim u m s e c

u rity inm ate s m ay s tay 5-6 m onths d u e to
lim ite d be d availability at pare nt ins titu tions . A t the tim e ofou r re view, m ore than 500 inm ate s
had be e n hou s e d at N R C longe rthan 60d ays .
T he m ajority ofthe proble m s we note d at this ins titu tion c
ou ld be trac
e d to the lac
k ofle ad e rs hip
at the fac
ility. T he H C U A is re s pons ible for both the N R C and State ville m e d ic
al program s .
H owe ve r, d u e to he r m e d ic
alle ave and s u bs e qu e nt prohibition by c
u s tod y to retu rn to he r work
are ad u e to am e d ic
ald e vic
e , e ac
h fac
ility thu s s u ffe rs from lac
k of le ad e rs hip. T his le ad e rs hip
vac
u u m s e riou s ly im pac
ts the tim e line s s and qu ality ofc
are provide d , and re s u lts in an abs e nc
e of
infras tru c
tu re to allow fors e lf-m onitoring, as willbe e vid e nc
e d in m u ltiple are as throu ghou t this
re port.
T he R e c
e ption C e nte rproc
e s s e s abou t 500-550intake s pe rwe e k, the m ajority from C ook C ou nty
Jail, bu t als o inc
lu d inginm ate s from arou nd the s tate who are on awrit to appe arin C ook C ou nty
c
ou rt. N u m e rou s iss u e s withC ook C ou nty Jailwe re re porte d , partic
u larly havingto d o withpoor
c
om m u nic
ation. N R C re porte d that the y ofte n d o not re c
e ive trans fe r s u m m aries and thu s m u s t
re ly on inm ate s e lf-re portingofalle rgies , c
u rre nt m e d ic
al/m e ntalhe althiss u e s , and m e d ic
ations .
T he re are no m e d ic
al hold s at C ook C ou nty Jail, s o an inm ate c
ou ld arrive one d ay and be
sc
he d u le d for s u rge ry the ne xt. W he n N R C s taffc
allthe jail, the y re port s u bs tantiald iffic
u lties
obtaininginform ation. Forthe s e re as ons , W e xford e m ploys as taffm e m be rwho re ports to C ook
C ou nty Jailthre e d ays awe e k to obtain c
u rre nt m e d ic
ation inform ation for inm ate s trans fe rring
into the N R C .
It s hou ld be m e ntione d that ou rre view was s e riou s ly ham pe re d by the lac
k oforganize d re c
ord
ke e pingat this ins titu tion. Logs we re e ithe r not re liably fille d ou t, or not ke pt at all. It was
im pos s ible to d isc
ove rthe ave rage age orle ngthofs tay ofthe popu lation. Sic
kc
alls lips we re not
file d in the re c
ord s , nor we re the y rou tine ly ke pt in any othe r loc
ation. Sic
k c
all logs we re
u nre liable and it was ofte n u pto the ind ivid u alprovid e rs to ke e ptrac
k ofthe s ic
ke s t patients whom
the y ne e d e d to follow.
T he R e c
e ption C e nte rplays ac
ru c
ialrole forinm ate s e nte ringthe D e partm e nt. It is at this ju nc
tu re
that patients withac
u te and c
hronicm e d ic
alc
ond itions m u s t be ide ntified and triage d and longte rm c
are plans initiate d . A t N R C , patients withm e d ic
alc
ond itions are ide ntified on arrivaland
s e e n by aprovide r, bu t typic
ally the plan e nd s he re . D e s pite the pre s e nc
e ofac
hronicc
are nu rs e ,
the re d id not appe arto be an organize d atte m pt to id e ntify patients withc
hronicd ise as e s and e nroll
the m in the c
hronicc
are program ;this was large ly le ft to the pare nt ins titu tions , e ve n forpatients
who we re d etaine d at N R C form onths . T he c
hronicc
are nu rs e was not available to m e e t withu s
forthe bu lk ofou rvisit.
T he re is no infirm ary u tilize d as s u c
hat N R C . P atients ne e d inginfirm ary le ve lofc
are are s e nt to
State ville . A llfou r of the N R C patients ad m itte d to the infirm ary at the tim e of ou r visit we re
c
hronic
/longte rm c
are , ye t the y we re s e e n at le as t thre e tim e s awe e k by the N R C M e d ic
al
D ire c
tor. C ons id e ringhow bu s y and u nd e rs taffe d the R e c
e ption C e nte rwas , it is ou ropinion that
the M e d ic
alD ire c
tor
s tim e wou ld be be tte rs pe nt foc
u s ingon the are as ofgre ate st ne e d .
Janu ary 2014
N orthern Rec epti

on C enter
P age 4
Inc
om ingpatients who are pote ntially or ac
tu ally u ns table , or who are ide ntified by the intake
nu rs e as ne e d ingim m e d iate atte ntion are re fe rre d to aprovide r forthe ir history and phys ic
alon
the d ay ofthe ir arrival. A llothe r rou tine intake history phys ic
als are s u ppos e d to be pe rform e d
within s e ve n d ays .
T he m e d ic
al re c
ord s are d isorganize d and not c
ond u c
ive to provid ingad e qu ate s e rvic
e s . A ll
d oc
u m e nts are d ropfile d ,m e aningloos e filingis d e pos ite d into the c
hart fold e rin no partic
u lar
ord er. T he re are tabs in the c
harts , and the re is am e d ic
al re c
ord s d e partm e nt, bu t nothingis
properly file d no m atte rhow longthe patients s tay at N R C . A llthe State ville M SU m e d ic
alre c
ord s
are m aintaine d in the N R C m e d ic
alre c
ord s room and thu s ne ve r be c
om e prope rly organize d for
the e ntire le ngthofthe ir s tay. T he m e d ic
alre c
ord s s u pe rvisor
s e xplanation is that the y s im ply
d on
t have tim e to pu t re c
ord s togethe r. T his d ropfilingphilos ophy is bas e d on the as s u m ption
that allpatients at N R C are part ofthe re c
e ption proc
e s s and thu s only s tay 1-2we e ks ;howe ve r,
this is ofte n not the c
as e .
T he C Q I program was e s s e ntially none xiste nt at N R C and of little to no u s e in e valu atingthe
e ffe c
tive ne s s ofthe program .
In s u m m ary, the he althc
are program at N R C s u ffe rs from lac
k ofle ad e rs hip, we ak infras tru c
tu re ,
d isorganization, re s ou rc
e s hortage s and abs e nt ove rs ight.
Findings
W ithre gard to le ad e rs hip, we obs e rve d this as am ajorare aofd e fic
ienc
y at N R C . T his was tru e
for both c
linic
alle ad e rs hip by the M e d ic
alD ire c
tor and ad m inistrative le ad e rs hip by the s tate
H C U A . T his c
om bine d le ad e rs hip vac
u u m has re s u lte d in aprogram ill organize d to provid e
qu ality s e rvic
e s to the m any patients who c
irc
u late throu gh the re c
e ption proc
e s s or who s tay
longe rpe riod s oftim e at N R C . From an abs e nc
e ofprofe s s ionalpe rform anc
e re view and fe e d bac
k,
to an abs e nc
e of c
ons c
ientiou s logging and trac
king, whic
h s hou ld be u s e d for proc
ess
im prove m e nt, to ad isorganize d m e d ic
al re c
ord s s ys te m , the N R C he althc
are program c
re ate s
avoidable liability forthe inm ate s and the s tate .
Staffingis c
om prise d ofac
om bination ofs tate and ve nd or pos itions . T he re is as tate e m ploye d
H C U A who is re s pons ible forboththe N R C and State ville , withState ville re qu iringm os t ofhe r
tim e . A d d itionally, the H C U A has be e n off-d u ty form e d ic
alre as ons s inc
e N ove m be r2013, and
was only available for approxim ate ly fou r hou rs d u ringou r fou r-d ay visit. T he re is a s tate
e m ploye d D ire c
torofN u rs ing(D O N )and s u pe rvisingnu rs e . T he m e d ic
alre c
ord s d e partm e nt is
s u pe rvise d by aW e xford e m ploye d R e giste re d H e althInform ation T e c
hnic
ian (R H IT ).
Janu ary 2014
N orthern Rec epti

on C enter
P age 5
O the rs taffingis liste d in the following

table :Table 1. Health Care Staffing
Position
M e d ic
alD ire c
tor
StaffP hys ic
ian
N u rs e P rac
titione r
D ire c
torofN u rs ing
C orre c
tions N u rs e I
C orre c
tions N u rs e II
Lic
e ns e d P rac
tic
alN u rs e s
C e rtified N u rs ingA id e
.
P hle botom ist
R ad iology T e c
hnic
ian
P harm ac
y Tec
hnic
ian
P harm ac
y Tec
hnic
ian
StaffA s s istant I
StaffA s s istant II
C hiefD e ntist
D e ntist
O ptom e try
P hys ic
alT he rapist
P hys ic
Total
Current FTE
1.0
1.0
2.8
1.0
1.0
1.0
Filled
1.0
1.0
3.0
1.0
1.0
1.0
Vacant
0
0
0
0
0
0
7.8
8.0
State/Cont.
C ontrac
t
C ontrac
t
C ontrac
t
State
State
State
Staffbe twe e n N R C and State ville C orre c

tionalC e nte ris inc
lu d e d in one c
ontrac
t/sc
he d u le E and
are s hare d be twe e n the two fac
ilities . T his s haringm ake s it d iffic
u lt to d ete rm ine ac
tu alpos itions
alloc
ate d c
om pare d to fille d pos itions ve rs u s vac
ant pos itions . W iththe e xc
e ption ofthe H e alth
C are U nit A d m inistrator (H C U A )pos ition, the above s taff FT E s are d e d ic
ate d to the N R C . O f
partic
u lar c
onc
e rn is the s hare d H C U A pos ition. T he N R C re c
e ive s approxim ate ly 550 ne w
inm ate s e ac
h we e k. If the N R C we re only aproc
e s s ingc
e nte r and inm ate s we re m ovingou t
qu ic
kly, s u pe rvisingnu rs ings taffc
ou ld be s u ffic
ient to m ake s u re the proc
e s s is c
om ple te fore ac
h
inm ate ;that is, e ac
hinm ate m ove d throu ghe ac
hs c
re e ningpoint, the appropriate inform ation was
c
olle c
te d and d oc
u m e nte d and allthe boxe s on the form we re c
he c
ke d , the intake proc
e s s was
appropriate ly c
om ple te d , and the inm ate was trans fe rre d . H owe ve r, this is not the c
as e . T he N R C
hou s e approxim ate ly 2300 inm ate s and has a pe rm ane nt popu lation of inm ate s who have
s ignific
ant ac
u te and c
hronicillne s s e s whic
h the re fore re qu ire s the ope ration of am e d ic
alu nit
ove rand above the proc
e s s ingc
e nte r.
Janu ary 2014
N orthern Rec epti

on C enter
P age 6
W hile ins pe c
tion ofthe re c
e ption proc
e s s ind ic
ate d no s ignific
ant nu rs ingiss u e s , the m e d ic
alu nit
s id e ofthe N R C pre s e nte d bothad m inistrative and m e d ic
alc
onc
e rns that, in ord e rto be prope rly
m onitore d and m anage d , re qu ire the ove rs ight of afu ll-tim e H C U A . A d d itionally, the c
u rre nt
H C U A has be e n on an e xte nd e d le ave ofabs e nc
e whic
hhas re s u lte d in no m e d ic
alad m inistrative
ove rs ight. W hile the re is a fu ll-tim e D ire c
tor of N u rs ingand fu ll-tim e s u pe rvisingnu rs e , the
volu m e ofintake and pe rm ane nt popu lation inm ate s c
ou ple d withs taffingiss u e s le ave the m with
no tim e to provide the ad m inistrative ove rs ight re qu ire d .
D e lays in ac
c
om plishing the re c
e ption proc
e s s within the re qu ire d tim e fram e s as we ll as
profe s s ionalpe rform anc
e proble m s s u gge s t that the re m ay be inad e qu ate re s ou rc
e s d e d ic
ate d to
this proc
ess.
A m ore d e taile d s taffings u m m ary willbe provide d in the State ville re port.

T he N R C re c
e ption are ais alarge room d ivid e d into s pe c
ificare as s u c
h as prope rty s torage ,
s e arc
he s , bu re au of ide ntific
ation, im m igration inte rviews , m e ntalhe alth inte rviews and alarge
m e d ic
alare awithm u ltiple s tations forthe following:
1.
2.
3.
4.
5.
6.
7.
8.
C olle c
tion and re c
ord ingofm e d ic
alhistory
C olle c
tion and re c
ord ingofhe ight, we ight, vitals igns
C ond u c
tingand re c
ord ingaSne lle n e ye c
hart e xam ination
A d m iniste ringatu be rc
u lin s kin te s t
C ond u c
tingafu ll-m ou thd e ntalx-ray and e xam ination
D rawingblood forbas e line laboratory valu e s
T hre e e xam ination room s foru rge nt c
are orc
hronicillne s s as s e s s m e nt
M e ntalhe alth
T he are a was c
le an, we ll lighte d and we ll m aintaine d . T he u s e of blood -borne pathoge n
pre c
au tions was obs e rve d , and pe rs onalprote c
tive e qu ipm e nt was im m e d iate ly available to staff.
O u ts id e the re c
e ption are abu t s tillwithin the N R C is the he althc
are u nit. T his is ave ry bu s y u nit
withalot offoot trafficbu t, at the tim e ofthe ins pe c
tion, appe are d re lative ly c
le an, we llm aintaine d
and we lllighte d . T he u nit c
ons ists of am e d ic
ation pre paration are a, pharm ac
y and m e d ic
ation
s torage , x-ray, thre e e xam ination room s , e m e rge nc
y/u rge nt c
are /proc
e d u re room , one c
haird e ntal
c
linic
, m e d ic
alre c
ord s , offic
e s pac
e s and an inm ate hold ingare a.
A c
ros s ahallway is a12-be d infirm ary whic
hhas ne ve rbe e n ope rationale xc
e pt foran e ight-be d
m e ntal he alth obs e rvation are a. Ins pe c
tors we re told the infirm ary has not be e n u s e d d u e to
ins u ffic
ient s taffing. Inm ate s re qu iring infirm ary plac
e m e nt are m ove d to the State ville
C orre c
tionalC e nte rm e d ic
alu nit infirm ary.
T he thre e e xam ination room s and u rge nt c
are room we re appropriate ly s ize d and e qu ippe d and
provide d for patient privac
y and c
onfid e ntiality. T he othe r are as , pharm ac
y, m e d ic
ation
pre paration, e tc
., we re appropriate ly s ize d and e qu ippe d s pe c
ificto the fu nc
tion ofthe room .
Janu ary 2014
N orthern Rec epti

on C enter
P age 7
T he ID O C blood -borne pathoge n polic

y and proc
ed u re s are u s e d . P e rsonalprote c
tive e qu ipm e nt
was available to staff, and alic
e ns e d m e d ic
alwas te hau le ris u s e d .
W hile c
u rre ntly the re is no c
linics pac
e provide d in the c
e llhou s e s , it appe are d the re was aroom
d e s igne d and bu ilt to be u s e d forc
e llhou s e s ic
kc
all, bu t the room s are be ingu s e d as offic
e s pac
e
by c
e llhou s e s e c
u rity s taff. Ifthe s e room s we re to be appropriate ly e qu ippe d , the y c
ou ld e as ily be
u s e d to c
ond u c
t s ic
kc
all, in that the m e d ic
alprovide r c
ou ld s pe ak with the inm ate /patient in
private , c
ond u c
t an e xam ination, as s e s s and tre at, whic
hwou ld e lim inate s om e ofthe iss u e s as
note d u nd e rthe N u rs ingSic
k C alls e c
tion.
Reception Processing
e ption C e nte rre c
e ption proc
e s s oc
c
u rs in awe ll-d e s igne d are awhic
hc
ontains a
s e qu e nc
e of s tations whe re d iffe re nt as pe c
ts of the proc
e s s are pe rform e d . O n ave rage ,
approxim ate ly 100-220intake s pe rd ay are proc
e s s e d M ond ay thru Frid ay. T his re s u lts in awe e kly
re c
e ption grou pofbe twe e n 500-550. A lthou ghthe re c
e ption proc
e s s is d e s igne d to be c
om ple te d
within one we e k, in fac
t the re c
e ption proc
e s s fors om e inm ate s m ay be s ignific
antly longe r. O n
ave rage , inm ate s s tay at the N orthe rn R e c
e ption C e nte rbe twe e n thre e and fou rwe e ks . T his is an
im portant fac
t be c
au s e the ad m inistrative d ire c
tive that d e als with c
hronicc
are d e s c
ribe s a
re qu ire m e nt that the firs t c
hronicc
are visit m u s t take plac
e within 30 d ays of arrival at the
pe rm ane nt ins titu tion, bu t this d ire c
tive pre s u m e s m ove m e nt afte rone we e k.
N R C re c
e ive s only an e m aile d list of m e d ic
ations from C ook C ou nty Jail for inm ate s be ing
trans fe rre d , bu t no othe rre c
ord s . T his is the only c
linic
alc
om m u nic
ation. H owe ve r, this list is not
typic
ally available to the staff at the tim e ofthe intake s c
re e ningor phys ic
ale xam . T he re have
be e n atte m pts at c
onne c
tivity withC ook C ou nty Jail, bu t the re have be e n m u ltiple obs tac
le s to
this. W e xford s taffhave atte m pte d to work m ore c
los e ly withC ook C ou nty Jail, bu t the R e gional
M e d ic
alD ire c
torind ic
ate s the re has be e n m inim alc
oope ration. C ook C ou nty Jailind ic
ate s the y
d o not have the s taffto re view re c
ord s priorto inm ate trans fe r.
P atients s c
he d u le d fors u rge ry orou ts ide appointm e nts at C ook C ou nty H os pitalare not plac
e d on
ahold by the jailin ord e r to ac
c
om m od ate the appointm e nt. A ls o, the re is no ad vanc
e d notic
e
re gard ingpatients arrivingon u nu s u alorc
ritic
alm e d ic
ations , thu s re s u ltingin avoid able d e lays in
re c
e ipt ofthe m e d ic
ations .
T he R e c
e ption C e nte r its e lf hou s e s approxim ate ly 2300 inm ate s and s om e inm ate s s tay longe r
pe riod s oftim e be c
au s e ofas hortage ofavailable m axim u m -s e c
u rity be d s . T he m e d ic
alportion
ofthe re c
e ption proc
e s s be gins witham e d ic
alhistory that is pe rform e d by am e d ic
alte c
hnic
ian,
alic
e ns e d prac
tic
alnu rs e or are giste re d nu rs e . T his m e d ic
alhistory d oe s not c
ontain qu e s tions
d e s igne d to ide ntify s ym ptom s c
u rre ntly pre s e nt in the patient. R athe r, it is m e ant to ide ntify
s ignific
ant c
hronicc
ond itions as we llas s pe c
ialne e d s and s u bs tanc
e u s e alongwithm e ntalhe alth
proble m s . P art ofthe m e d ic
alhistory inc
lu d e s ac
olle c
tion ofobje c
tive d ata, inc
lu d ingvitals igns ,
he ight and we ight and avision e xam . T he re is as e c
tion foras s e s s m e nt and the n as e c
tion forplan,
whic
his u s e d to ide ntify the ne e d foran u rge nt phys ic
ale xam orm e ntalhe althre fe rralas we llas
T B re s u lts . T he latte r m ay be proble m aticbe c
au s e on oc
c
as ion the phys ic
ale xam is pe rform e d
be fore it is appropriate to re ad the tu be rc
u los is te s t e xam .
Janu ary 2014
N orthern Rec epti

on C enter
P age 8
A fte rthe history is pe rform e d ad e ntale xam inc

lu d ingaP anare x is pe rform e d , as we llas labte s ts
and whe re ind ic
ate d , e le c
troc
ard iogram orc
he s t x-ray. Su bs e qu e nt to the history be ingpe rform e d ,
u s u ally within one we e k, an ad vanc
e d le ve l c
linician, that is a phys ician as s istant, nu rs e
prac
titione rorphys ician, pe rform s aphys ic
ale xam as we llas ahistory ge are d to s u bs tanc
e u se,
highrisk be haviorand T B s ym ptom qu e s tions . A gain, the re are no s tru c
tu re d qu e s tions to e lic
it
any othe rc
u rre nt s ym ptom s . A fte rthe phys ic
ale xam , the re is an are aforthe d e ve lopm e nt ofa
proble m list as we llas hou s ingplac
e m e nt c
ons id e rations and ad e te rm ination of food hand le r
s tatu s . U nfortu nate ly, the re is c
u rre ntly no proc
e s s to ins u re that the T B re s u lts , the blood te s t
re s u lts and whe re ind ic
ate d an e le c
troc
ard iogram orc
he s t x-ray are inte grate d into afinalproble m
list and plan fore ac
hproble m priorto patients be ingtrans fe rre d to the pe rm ane nt fac
ility.
A t the tim e ofou rvisit, the re we re be twe e n 200and 300re c
ord s ofpatients who had re c
e ive d a
nu rs e s c
re e n and who we re awaitingaphys ic
ale xam by an ad vanc
e d le ve lc
linic
ian. Som e ofthe s e
re c
ord s re fle c
te d patients who we re ad m itte d m ore than two we e ks priorto ou rvisit. W e we re told
that the re s om e tim e s is aproble m withc
u s tod y provid ingalist ofpatients to be s e nt ou t, whic
h
m ay inc
lu d e patients who have not ye t had aphys ic
ale xam . W e we re inform e d that the program
is able to bringin an ad vanc
e d le ve lc
linic
ian who has c
om ple te d as m any as 25phys ic
ale xam s
within 3-4hou rs . A lthou ghs u c
haphys ic
ale xam m ay m e e t as s e m bly line re qu ire m e nts , itis highly
u nlike ly that s u c
he xam s re fle c
t an appropriate qu ality s tand ard .
W e we re als o inform e d that the re is aR e c
e ption C e nte rstaffpe rs on who is at C ook C ou nty Jail
from whic
hthe bu lk ofthe trans fe rs into re c
e ption arrive . She is at the jailthre e orfou rd ays pe r
we e k and is able to obtain c
u rre nt m e d ic
ation lists from the pharm ac
y. W e have be e n told that
C e rm ak/C ook C ou nty Jailis workingwithIT to c
re ate an e le c
tronictrans fe r s u m m ary that will
inc
lu d e ac
u rre nt proble m list, m e d ic
ations , alle rgies , and any othe rm e d ic
alne e d s that m ay re qu ire
atte ntion. It is not c
le arwhe n this s hou ld be c
om e available . W e d o know that c
om ple x patients are
arrivingwithno m e d ic
alhistory othe rthan the m e d ic
ation list. W he n the s e patients arrive , e fforts
m u s t be m ad e to obtain c
ritic
alpatient inform ation from C ook C ou nty Jail. D e s pite s ignific
ant
d e lays , patients are be ingproc
e s s e d throu gh;howe ve r, we have id e ntified s ignific
ant qu ality
iss u e s .
A bs e nc
e ofs trongle ad e rs hip at N R C has m ad e ou r tas k m u c
h m ore d iffic
u lt. T he H e althC are
A d m inistratorpos ition is he ld by ape rs on who has be e n on fre qu e nt le ave s ofabs e nc
e and it d oe s
not appe ar that anyone e ls e has s te ppe d u pto fu nc
tion as ale ad e r in the fac
e ofthis le ad e rs hip
vac
u u m . W e fou nd that the logs whic
hare re qu ire d forinte rnalm onitoringofthe program at N R C
are fre qu e ntly not m aintaine d and the re fore it was ve ry d iffic
u lt for u s to re view re c
ord s within
s pe c
ificc
ate gories .
W e re viewe d 35re c
ord s ofpatients who had e nte red within the las t m onthto m onthand ahalfand
who wou ld be trans fe rre d the followingd ay. E le ve n ofthe 35re c
ord s we re proble m aticin one or
m ore ways . O ne ofthe re c
ord s was ofapatient who e nte re d in O c
tobe roflas t ye ar. W hat follows
is alist ofproble m s id e ntified .
Patient #1
Janu ary 2014
N orthern Rec epti

on C enter
P age 9
T his patient was ide ntified as havingapos itive tu be rc

u los is s kin te s t bu t this was not ad d re s s e d
by the phys ic
ian and d oe s not appe aron the proble m list and the re fore als o lac
ks an ord e rfor a
c
he s t x-ray.
Patient #2
T his patient e ntere d on 10/8/13withan ope n wou nd on his c
oc
c
yx and paraple giaand hype rte ns ion.
H e als o had u rinary inc
ontine nc
e . H e has be e n hou s e d in the State ville infirm ary and has be e n
followe d forhis wou nd and the paraple gia, bu t has not ye t had ac
hronicc
are c
linic
.
Patient #3
T his patient
s intake labs ind ic
ate d s ignific
antly e le vate d live rfu nc
tion te s ts not ad d re s s e d by the
phys ic
ian and withou t any follow-u p.
Patient #4
T his patient
s intake re ve ale d hype rlipid e m iabu t the re has be e n no follow-u p.
Patient #5
T his patient had a blood pre s s u re on intake of 149/83. H e was liste d as havinga history of
hype rte ns ion bu t has not be e n takingany m e d ic
ine and the re was no follow-u pand no m e ntion of
his e le vate d blood pre s s u re .
Patient #6
T his patient was ide ntified as havinga20 m m pos itive T B s kin te s t whic
hthe phys ic
ian ne ve r
notic
e d and the re was no follow-u p.
Patient #7
T his patient
s labwork ind ic
ate s abnorm allive rfu nc
tion bu t the re has be e n no follow-u p.
Patient #8
T his patient on intake had an e le vate d blood pre s s u re whic
hwas ne ve rre pe ate d . T he patient als o
had hype rlipid e m iawhic
hwas not liste d on the proble m list and has not be e n followe d u p.
Patient #9
T his patient had an e le vate d blood pre s s u re on intake whic
hwas not re pe ate d and d oe s not s e e m
to have be e n ide ntified .
Patient #10
T his patient e nte re d the R e c
e ption C e nte ron 12/28/13bu t has not had his phys ic
ale xam ye t.
Patient #11
T his patient was ide ntified as havingan e le vate d blood pre s s u re whic
hwas re pe ate d and he was
plac
e d on tre atm e nt bu t has had no c
hronicc
are visit e ve n thou ghhe e nte re d on 12/10/13.
T he s e proble m s s u gge s t an abs e nc
e ofc
los e m onitoringand qu ality c
ontroland are like ly to le ad
to proble m s in the fu tu re forsom e ofthe s e patients .
Janu ary 2014
N orthern Rec epti

on C enter
P age 10
P riorto trans fe r, m e d ic
alre c
ord s s taffre views alld oc
u m e ntation to e ns u re e ve rythingis c
om ple te .
W e looke d at arand om s am ple of10c
harts ofpatients who we re d e taine d at the R e c
e ption C e nte r
form ore than 60d ays . Five ofthe 10patients had c
hroniche althiss u e s , ye t none had be e n e nrolle d
in the c
hronicc
are program orhad his c
hronicd ise as e intake e valu ation as d ic
tate d by polic
y.
Patient #12
T his patient arrive d 11/1/13. H e is 56-ye ar-old m an with d iabe te s , hype rlipid e m ia, GE R D and
c
hronickne e pain. H e is not e nrolle d in the c
hronicc
are program norhas his A 1corlipid s be e n
c
he c
ke d s inc
e he
s be e n he re .
Patient #13
T his patient arrive d 11/7/13. H e is a23-ye ar-old withhistory ofas thm awhic
hwas as ym ptom atic
at the tim e of his intake phys ic
al, thou gh no d ise as e s pe c
ifichistory was d oc
u m e nte d by the
e xam iningprovid e r. T he albu te rolinhale rhe c
am e in withwas not c
ontinu e d and he was ins tru c
te d
to retu rn to the H C U ifhe d e ve lops s ym ptom s . H e is not e nrolle d in c
hronicc
are and has not be e n
s e e n s inc
e.
Patient #14
T his patient arrive d 11/7/13withahistory ofs e izu re d isord e roffm e d s , las t s e izu re las t ye ar.H e
has not ye t had aphys ic
ale xam .
Patient #15
T his patient arrive d on 11/14/13. H e is a28-ye ar-old withhistory ofas thm aon albu te rolwithpe ak
flow of400at tim e ofintake and blood pre s s u re 132/91. T he history ofas thm awas ove rlooke d at
the tim e ofhis phys ic
ale xam on 11/29, and his blood pre s s u re was not re c
he c
ke d . It d id not appe ar
that his albu te rolwas ord e re d as the re we re no ord e rs he e ts in the c
hart. H is intake labs s howe d a
m ild ly e le vate d alt (live re nz ym e )of89. H e is not e nrolle d in the c
hronicc
are program , norwas
he s e e n again.
Patient #16
T his patient arrive d on 11/15/13. H e is a45-ye ar-old m an withas thm aon albu te roland inhale d
s te roid whos e pe ak flow on intake was 450. Intake phys ic
ale xam was on 11/30;pe ak flow was
not re pe ate d . P atient was s e e n on 12/19 withs hortne s s ofbre ath, havingru n ou t ofhis inhale r.
P e ak flow was 200, 250. O xyge n s atu ration was not m e as u re d . P hys ic
ian note d no whe e z ingon
e xam ;as s e s s m e nt is h/o as thm aand re ord ere d the albu te rolinhale rwithaplan to have the patient
follow u pat his finalins titu tion. H e is not e nrolle d in c
hronicc
are program .
Medical Records
W e had e norm ou s d iffic
u lty re viewingm e d ic
alre c
ord s forany patient withs ignific
ant proble m s ,
the re ason be ingthat the proc
ed u re at N R C is to d ropfile alld oc
u m e nts in the re c
ord s. W hat
this m e ans is that d oc

u m e nts are not fas te ne d c
hronologic
ally in s pe c
ifics e c
tions ;ins te ad e ac
h
d oc
u m e nt is plac
e d loos e ly be twe e n the c
ard board c
ove rs . Forapatient pu re ly in re c
e ption whe re
Janu ary 2014
N orthern Rec epti

on C enter
P age 12
11
all of the re c
e ption d oc
u m e nts are staple d togethe r, this is not u nre asonable . H owe ve r, as we
le arne d , ove r500ofthe 2300inm ate s as s igne d to N R C have be e n at the fac
ility forgre aterthan 60
d ays . Se ve ralof the s e patients have m u ltiple s e riou s proble m s . To lite rally d rop progre s s note s,
m e d ic
ord s, x-ray re ports, laboratory re s u lts , intake re c
ord s, etc
., loos e ly in
no s pe c
ificord er c
re ate s c
haos forthe c
linic
ians the re to atte m pt to provide he alths e rvic
e s . It is
like ly that im portant inform ation whic
hm ay in fac
t be in the re c
ord willnot be loc
ate d . In ad d ition,
the u s u altype s of loggingand trac
kingwe re not be ingpe rform e d , thu s fu rthe r c
om plic
atingthe
ins titu tion
s ability to m onitorits e lf. D ropfilings hou ld not be d one forany patients withs ignific
ant
proble m s and allpatients who are at N R C form ore than 30d ays .
Nursing Sick Call

Sic
kc
alls lips are c
olle c
te d by the offic
e rs , who plac
e the m in the s ic
kc
allbox. M e d te c
hs (who
m u s t now be LP N s , bu t the re are s om e who are not who have be e n grand fathe re d in)c
olle c
t the m
from the boxe s and triage the m ac
c
ord ingto protoc
ols . T re atm e nt protoc
ols have re c
e ntly be e n
re vise d and are be ingrolle d ou t now. Ifthe y c
annot ad d re s s the m viaprotoc
ol, the y are re fe rre d to
nu rs e s ic
kc
all. N u rs e s ic
kc
allis c
om bine d withP A and nu rs e prac
titione rs ic
kc
all.
A nu rs e rou nd s in s e gre gation d aily c
e ll to c
e ll, an M D onc
e we e kly. P atients ne e d ingto be
e xam ine d are e s c
orte d to the c
linicare a.
It was re porte d that s ic
kc
allis c
ond u c
te d s e ve n d ays pe r we e k. T he proc
e s s was e xplaine d as
follows :
1.
2.
3.
4.
5.
Inm ate c
om ple te s re qu e s t and s u bm its to hou s ingu nit offic
e r.
O ffic
e rplac
e s the re qu e s t in aloc
ke d s ic
kc
alld ropbox loc
ate d in e ac
hc
e llhou s e .
M e d ic
als taffc
olle c
ts and triage s the re qu e s ts d aily.
T riage d re qu e s ts are c
ate gorize d as to u rge nt orrou tine .
P atients c
ate gorize d as havingan u rge nt re qu e st are s c
he d u le d to be e valu ate d the s am e
d ay. P atients c
ate gorize d as havingarou tine re qu e s t are s c
he d u le d to be e valu ate d within
72hou rs oftriage .
6. A he alth c
are s ic
k c
all log is to be m aintaine d whic
h note s the d ate, tim e , d e taine e
nam e /nu m be r, d ate re qu e s t re c
e ive d and triage d , d ate s c
he d u le d and d ate ac
tu ally
e valu ate d .
W e re the above s te ps followe d , the re wou ld be c
om plianc
e withpolic
y e xc
e pt forite m 2, whic
h
is abre ac
hofc
onfid e ntiality. In ac
tu ality, it is d iffic
u lt ifnot im pos s ible to trac
k s ic
kc
alld u e to
the lognot be ingm aintaine d . In ad d ition, the re qu e s ts we re ne ithe rfile d in the m e d ic
alre c
ord nor
available to the s e re viewe rs . T he M e d ic
alD ire c
toris re qu ire d to re view two m e d ic
alre c
ord s pe r
s ic
kc
allprovide r pe r m onthin ord e rto e valu ate appropriate ne s s ofc
are . H owe ve r, this was not
be ingac
c
om plishe d .
W e we re u nable to m e thod ic
ally re view the pe rform anc
e of nu rs e s ic
k c
all d u e to lac
k of
c
om plianc
e withpolic
y.
Provider Sick Call

Janu ary 2014
N orthern Rec epti

on C enter
P age 13
T he s ic
kc
alllogs are not fille d ou t re liably, bu t the fe w we we re able to re view ind ic
ate d that the
provide ris s c
he d u le d to s e e 20-25patients pe rd ay, som e tim e s m ore .
Patient #1
T his patient is a55-ye ar-old m an who arrive d at N R C on 12/12/13withahistory ofkne e arthritis.
H e plac
e d as ic
kc
allre qu e s t on 1/7 for an ingrown toe nail. H e was give n an appointm e nt on
1/18/14;howe ve r, he trans fe rre d to State ville M SU on 1/11/14. H e c
om plaine d of an ingrown
toe nailat his intake as s e s s m e nt and s aw the phys ic
ian that d ay, who only ad d re s s e d the kne e
arthritis. W he n he s aw the phys ic
ian again on the pre viou s ly s c
he d u le d 1/18 visit, the visit
ad d re s s e d aviralinfe c
tion and the re was no m e ntion ofthe toe nail. O n 1/19, the LP N s aw him
forabd om inalpain and he ad ac
he and the plan was to re fe rto the phys ic
ian forfu rthe re valu ation
on 1/18(the d ay priorto this visit). In the e nd , the ingrown toe nailhas ne ve rbe e n ad d re s s e d .
Patient #2
T his patient is a49-ye ar-old m an who arrive d at N R C on 12/23/13withahistory ofm e ntalillne s s ,
and had his phys ic
ale xam on 12/26. H e was als o s e e n on 1/3, 1/10, 1/18/14, bu t the re we re no
re qu e s t form s in the c
hart. O n 1/18, the LP N s aw the patient at 3:00 a.m . for pos s ible s e izu re
ac
tivity witne s s e d by the c
e llm ate . T he patient state d he ne e d e d bac
k his s e izu re m e d ic
ation. T he
nu rs e re fe rre d the patient to the d oc
torthe ne xt d ay and he was s e e n. It was d ete rm ine d by the
provide rthat the patient had be e n takingK lonopin foranxiety, not s e izu re s , and re fe rre d the patient
to m e ntalhe alth.
Patient #3
T his patient is a24-ye ar-old paraple gicm an who arrive d at N R C on 12/30/13havinghad are c
e nt
gu n s hot wou nd to the right arm (12/3/13). H is phys ic
ale xam was d one on 12/30. H e was als o
s e e n by the provide ron 1/2, 1/8, 1/22/14, bu t the re was no s ic
kc
alls lipin c
hart.
Patient #4
T his patient is a50-ye ar-old m an withahistory ofhe patitis C who arrive d at N R C on 1/2/14and
had his phys ic
ale xam on 1/14/14. H is labs d rawn on 1/17s howe d m ild ly e le vate d biliru bin and
+he patitis C antibod y. T his re s u lt was printe d on 1/18and re viewe d on 1/22by the P A who re fe rre d
the patient to s ic
kc
alland s aw him he rs e lfthat d ay.
Patient #5
T his patient is a28-ye ar-old m an withare porte d history ofirritable bowe ls ynd rom e on ad m iss ion
on 11/25/13;howe ve r, he was pre s c
ribe d m e s alam ine , whic
hind ic
ate s that he ac
tu ally like ly has
inflam m atory bowe ld ise as e , afar m ore s e riou s c
ond ition than irritable bowe ls ynd rom e . T he
provide r who pe rform e d the phys ic
ale xam faile d to re c
ognize this and pe rpe tu ate d the irritable
bowe ls ynd rom e d iagnos is. T he patient appe are d to have be e n we llc
ontrolle d on m e s alam ine 2000
m gqid u pon ad m iss ion. H owe ve r, the m e d ic
ation was c
hange d on arrivalto D e lz ic
ol800 m g,
thre e tim e s ad ay for 30 d ays . T he re is anote from the P A on 12/24 re gard ingthe patient
s
inflam m atory bowe ld ise as e and that he re porte d blood y d iarrhe aforthe pas t fe w we e ks . T he re is
no s ic
kc
alls lipin the c
hart. H e is s tillat N R C and he is not e nrolle d in the c
hronicc
are program .
Patient #6
Janu ary 2014
N orthern Rec epti

on C enter
P age 14
T his patient is a 35-ye ar-old who arrive d at N R C on 1/2/14 with m e ntal illne s s and he roin
withd rawaland history ofs e izu re s on no m e d s . H e was s e e n by the P A on 1/22forwe akne s s ;the re
is no s ic
kc
alls lipin the c
hart.
Patient #7
T his patient is a31-ye ar-old m an who arrive d at N R C on 1/10/14 withno m e d ic
alhistory. H is
blood pre s s u re was e le vate d on arrival;155/103, re pe at 162/98. A t his intake phys ic
ale xam the
ne xt d ay, his blood pre s s u re was stille le vate d and he was s tarte d on hyd roc
hlorothiaz id e . H is
intake blood te st was d rawn on 1/10, printe d on 1/11, and s howe d e le vate d live r fu nc
tion te s ts .
T he y we re re viewe d on 1/14by the P A , who re qu e s te d follow u p(by notingthis on the lab-was
no ord e rfou nd on ord e rs he e t), bu t the patient had not be e n s e e n as ofthe d ate ofou rre view (1/23).
Patient #8
T his patient is a47-ye ar-old m an who arrive d at N R C on 1/10/14 and had his intake phys ic
al
e xam on 1/11, intake labs d rawn on 1/10, and printe d on 1/11, whic
hs howe d e le vate d c
re atinine .
Follow u p withaprovid e r was note d on the labre port;this s ignatu re was not d ate d . A s ofthe
d ate ofou rre view (1/23), he had not ye t be e n s e e n, norc
ou ld anyone te llm e whe n he wou ld be
s e e n.

A c
c
ord ingto the inform ation we we re provide d , the re we re at m os t 35 patients e nrolle d in the
c
hronicc
are program . C ons id e ringthat ne arly 600inm ate s we re d etaine d at the R e c
e ption C e nte r
forove r60d ays at the tim e ofou rvisit, this nu m be ris inc
re d ibly s m all.
P atients withc
hronicd ise as e s are s u ppos e d to be s e e n forthe irinitialc
hronicc
are intake within 30
d ays ofarrivalat the irpare nt fac
ility orat the R e c
e ption C e nte rifhou s e d the re forove r30d ays .
T his is not happe ningat N R C . P atients withc
hronicd ise as e s are s u ppos e d to be ide ntified at intake
and re fe rre d to the c
hronicc
are nu rs e . H owe ve r, the c
hronicc
are nu rs e was not available form ost
ofou r visit and he r trac
kings ys te m was u nfam iliar to any othe r staff m e m be r, and so we we re
u nable to as c
e rtain the natu re ofthe s ys te m , ifthe re is one in plac
e at N R C .
T he c
hronicc
are form s in u s e at this ins titu tion have not be e n u pd ate d in 12ye ars . E nrollm e nt in
c
hronicc
are c
linicis inc
ons iste nt at be s t. A t the tim e ofou rvisit, the re we re abou t 20patients on
m e d ic
alhold s , m any for ongoingtre atm e nt ofc
hronicc
ond itions s u c
has c
anc
e r, bu t none we re
e nrolle d in the c
hronicc
are program . T he O T S trac
ks thos e patients withc
hronicd ise as e s , bu t this
list is only as ac
c
u rate as the inform ation fe d into it. T he c
hronicc
linicnu rs e ke e ps he rown list,
whic
hwas inc
ons iste nt withthe O T S list.
Inm ate s ide ntified d u ringintake as havingac
hronicillne s s are e valu ate d and , ifne e d e d , provide d
m e d ic
ation, bu t the bas e line c
hronicillne s s c
linicis not c
ond u c
te d u ntilthe inm ate re ac
he s his
pe rm ane nt fac
ility.
A re view ofand inte rviews withd iabe ticinm ate s on ins u lin willbe c
ond u c
te d and re porte d in the
State ville re port.
O n apos itive note , labs are c
ons iste ntly d rawn tim e ly priorto the c
hronicc
are c
linicvisits .
C ard iac
/H ype rte ns ion (25)
D iabe te s (8)
Ge ne ralM e d ic
ine (0)
H ighR isk (0)
H IV Infe c
tion/A ID S (0)
Live r(0)
P u lm onary C linic(0)
Se izu re C linic(2)
T B infe c
tion (1)
Cancer
Patient #1
T his patient is a53-ye ar-old m an with m e tas taticpanc
re aticc
anc
e r who arrive d at N R C on
6/13/13 and has be e n on am e d ic
al hold s inc
e that tim e to re c
e ive tre atm e nt at U nive rs ity of
Illinois. H e has be e n s e e n tim e ly at N R C and at U nive rs ity ofIllinois. It d oe s not appe arthat he
is e nrolle d in the c
hronicc
are program , thou ghhe has be e n s e e n re gu larly forhis c
anc
e rfollowu p.
T he c
hronicc
are form lists blood pre s s u re goals for variou s d e gre e s ofc
ontrolon the bac
k, for
patients withand withou t d iabe te s . H owe ve r, the d iabe ticblood pre s s u re goals are c
u t offfrom the
form .
Diabetes
N P H ins u lin is ofte n ord e re d as an as ne e d e d m e d ic
ation this is not appropriate u s e ofthis age nt.
C linic
s are not oc
c
u rringm ore fre qu e ntly than the antiqu ate d Janu ary/M ay/Se pt s trate gy ou tline d
in the ou td ate d polic
y from 2002.
Patient #2
T his patient is a31-ye ar-old d iabe ticwithre tinopathy and hype rte ns ion who arrive d at State ville
on 5/28/12. H e is on Lantu s , lisinopril, A te nololand s im vas tatin. T he re is an u nd ate d and totally
ille gible c
hronicc
are note at whic
htim e the patient
s blood pre s s u re was 152/90. T his was d e e m e d
fair c
ontroland it d oe s not appe arthat any m e d ic
ation c
hange s we re m ad e . T he form was file d
toward the front ofthe c
hart, le ad ingu s to think it was the m os t re c
e nt note . P ile d ne arit we re lab
re ports from 11/25/13;howe ve r, no A 1cwas obtaine d . Som e thingind e c
iphe rable was s c
ribble d
in the f/u appointm e ntbox.
T he re is anothe r c
hronicc
are visit d ate d 9/21/13 in the s am e ille gible s c
ribble . A t this visit, the
patient
s blood pre s s u re was 145/92, bu t no c
hange is m ad e to his blood pre s su re m e d ic
ation. H is
d iabe te s appe are d to be u nd erfairly good c
ontrolwithan A 1cof7% on 9/5/13, ye t his Lantu s
Janu ary 2014
N orthern Rec epti

on C enter
P age 15
was inc
re as e d from 30to 35u nits at be d tim e . H is lipid s we re above goaland as tatin was ad d e d .
It appe ars that the provide rwants to s e e the patient bac
k in 10d ays , bu t again, it is d iffic
u lt to te ll
give n the natu re ofthe hand writing.
T he patient is re pe ate d ly ord e re d ibu profe n 400-800 m gthre e tim e s ad ay as ne e d e d , whic
h is
re lative ly c
ontraind ic
ate d give n his poorly c
ontrolle d hype rte ns ion.
A third c
hronicc
are note is d ate d 5/18/13. T he re we re labs d one thre e d ays priorto the appointm e nt
bu t file d d e e pwithin the s tac
k ofpape rs . O fnote , the patient
s T SH has be e n e le vate d on s e ve ral
oc
c
as ions bu t not e xplore d fu rthe r.
Patient #3
T his patient is a23-ye ar-old type 1d iabe tics inc
e age 17, who arrive d at State ville on 8/24/12. H e
is ord e re d N P H in the m orningon an as ne e d e d bas is ifhis blood glu c
os e is gre ate rthan 200and
Lantu s at be d tim e . H e is ord e re d twic
e -d aily A c
c
u -C he ks , bu t the M A R s ind ic
ate that his blood
glu c
os e is only c
he c
ke d onc
e ad ay in the e ve ning;the re fore , the re are no d oc
u m e nte d d os e s of
N P H . H is A 1chas be e n s te ad ily risingfrom 5.2% on ad m iss ion to the m os t re c
e nt A 1cof11.4%
in A u gu s t of2013. H is ins u lin ord e rs have re m aine d alm os t u nc
hange d forthe e ntire le ngthofhis
s tay d e s pite the d ram aticd e c
line in his d ise as e c
ontrol.
T he re was only one c
hronicc
are c
linicnote in the he althre c
ord ;this was d ate d 9/21/13and in the
s am e ille gible hand writingas the othe rs . H is d iabe te s c
ontrolwas ac
knowle d ge d to be poor, ye t
no c
hange s to his ins u lin we re m ad e . H e has not be e n s e e n forc
hronicc
are follow u ps inc
e.
Patient #4
T his patient is a32-ye ar-old d iabe ticwho arrive d at State ville on 6/1/12 on oralm e d s . H e was
s tarte d on ins u lin in O c
tobe rof2012in re s pons e to arisingA 1c(9.2% ). H is las t thre e c
hronicc
are
c
linicvisits oc
c
u rre d on 2/28/13, 5/18/13, and 9/21/13. A t the 2/28/13visit, he was on Lantu s 40
u nits at be d tim e and N P H in the m orningifhis blood glu c
os e was gre ate rthan 200. A c
c
u -C he ks
we re ord e re d bid bu t only d oc
u m e nte d in the pm , s o no d oc
u m e nte d d os e s ofN P H we re give n.
A t the 5/18/13 visit, whic
his ille gible , the A 1cwas im prove d at 7.7% . A t the 9/21/13 visit, the
A 1cwas u pto 8.7% bu t no ad ju s tm e nts to the ins u lin re gim e n we re m ad e . H e has not be e n s e e n
s inc
e.
General Medicine
Patient #5
T his patient is a27-ye ar-old m an withahistory ofO R IFofright tib/fibin 2011who now has the
proxim alfixatings c
re w bac
kingou t ofthe IM rod abou t 1-2c
m into the s oft tiss u e s ofhis lowe r
e xtre m ity. T his was e vid e nt at his ad m iss ion history and phys ic
alon 9/3/13. H e was approve d on
10/2/13 forortho c
ons u lt for re m ovalofthe hard ware and as ofthe d ate ofou rvisit, he had not
be e n s e e n. D isc
u s s ion with the s c
he d u le r/m e d ic
al re c
ord s s u pe rvisor, A d rianne , e xplaine d that
e xc
e s s ive ly longwait tim e s throu gh U nive rs ity of Illinois-C hic
ago (5-6 m onths )c
ontribu te d to
this d e lay. She was u ltim ate ly able to ide ntify an alte rnative provide rwithwhom
Janu ary 2014
N orthern Rec epti

on C enter
P age 16
W e xford has c
ontrac
te d to provid e s e rvic
e s and has him s c
he d u le d on 1/28/14. H e is not e nrolle d
in the c
hronicc
are program
Patient #6
T his patient is a36-ye ar-old m an withinflam m atory bowe ld ise as e on H u m irawho arrive d at N R C
on 9/19/13 and was plac
e d on a m e d ic
al hold . H e was hos pitalize d twic
e for flare s of his
inflam m atory bowe ld ise as e from 11/912/15. H e was hou s e d in infirm ary for23hou rs u pon his
re tu rn from the hos pitaland he was s e e n by the P A on 12/24 afte r his re tu rn to N R C . H e is not
e nrolle d in the c
hronicc
are program
Patient #7
T his patient is a31-ye ar-old m an who arrive d at N R C on 11/5/13withac
om plic
ate d ortho history
ofs c
aphoid frac
tu re withnonu nion s /p re s e c
tion, fu s ion and bone graftingin O c
tobe r 2013. H e
was approve d forortho follow u pon 12/24and was s e e n on 1/17, bu t no re port was in the c
hart.
T he re port was obtaine d u pon ou rre qu e s t. T he K wire s we re re m ove d at this appointm e nt and it
appe ars the frac
tu re and fu s ion have he ale d . H e is to follow u pon an as ne e d e d bas is. H e is on a
m e d ic
alhold . H e is not e nrolle d in c
hronicc
are program .
HIV Infection/AIDS
H IV and he patitis C s e rvic
e s are provide d viate le m e d ic
ine from U nive rs ity ofIllinois s taff.
Pulmonary
Patient #8
T his patient is a67-ye ar-old m an who was ad m itte d to N R C on 1/14/14 with m u ltiple m e d ic
al
proble m s inc
lu d ingoxyge n d e pe nd e nt C O P D and c
hronicantic
oagu lation foratrialfibrillation. H e
was note d to be s hort of bre ath on arrival and ad m itte d d ire c
tly to the infirm ary with C O P D
e xac
e rbation and atrialflu tte rwithahe art rate ofapproxim ate ly 100bpm . It d oe s not appe arthat
an IN R was ord e re d on ad m iss ion d e s pite his be ingon C ou m ad in, whic
hwas ord e re d .
W hile in the infirm ary, he was s e e n by the phys ic
ian on 1/15and 1/17(the d ate ofd isc
harge ). O n
1/21, it was note d that his IN R had not be e n c
he c
ke d and was ord e re d to be d one that d ay
(ye s te rd ay).
Seizure Disorder
Patient #9
T his patient is a19-ye ar-old with as e izu re d isord e r who arrive d at N R C on 7/13/13 and is on
m e d ic
alhold d u e to an e le vate d D ilantin le ve l.
TB Infection Clinic
T he P A re porte d that tre atm e nt forlate nt T B infe c
tion is d e laye d u ntilthe patient is trans fe rre d to
the pare nt ins titu tion. She s tate d that s he pre s c
ribe s patients who are goingto boot c
am pR ifam pin
x 4m onths whic
his not d ire c
tly obs e rve d the rapy. She s tate s that s he d oe s this in ord e rnot to hold
u pthe irgoingto c
am p.
Janu ary 2014
N orthern Rec epti

on C enter
P age 17
A d d itionally, the T B s kin te s ts are re ad at 2:00a.m ., and we have good re as on to be lieve as are s u lt
ofou rd isc
u s s ions withs taffthat the ac
c
u rac
y ofthe re ad ingis highly qu e s tionable at be s t, ofte n
c
ons istingofgaz ingu pon the patient
s arm from the c
e lld ooras he lies in be d .
Patient #10
T his patient was the only patient on IN H tre atm e nt at the tim e ofou rvisit. H is intake T B s kin te s t
was +20 m m on 3/8/13. It was not m e ntione d on his u nd ate d phys ic
ale xam . C he s t x-ray was
pe rform e d on 3/11 and was ne gative . T he re is no d oc
u m e ntation of s ym ptom as s e s s m e nt in
re lations hipto the pos itive s kin te s t. H e re fu s e d H IV te s tingon intake and it d oe s not appe arthat
this was e ve r re ad d re s s e d withhim as part ofthe T B tre atm e nt program . H e was trans fe rre d to
State ville M SU on 5/11/13and s tarte d on the rapy on 6/3/13. T he re are c
hronicc
are c
linicnote s
on 6/3and 7/8;no fu rthe rm onthly as s e s s m e nts we re fou nd in the c
hart. R e view ofthe M A R s hows
s e ve n m iss e d d os e s of m e d ic
ation;one re fu s al, two no s hows , one not in c
e lland thre e blanks
whic
hs hou ld be tre ate d as m e d ic
ation e rrors.
P e r polic
y, m e d ic
ation is provide d in bliste r pac
k c
ard s for ke e p on pe rs on (K O P ) s e lfad m inistration and s ingle d os e watc
h take ad m inistration by lic
e ns e d m e d ic
al s taff. In
pre paration for m e d ic
ation ad m inistration, m e d ic
al s taff id e ntify the appropriate inm ate
m e d ic
ord (M A R ) and m e d ic
ation bliste r pac
k. T he appropriate d os e of
m e d ic
ation is re m ove d from the bliste r pac
k and plac
e d in as m all e nve lope labe le d with the
patients nam e , nu m be r, c
e ll hou s e loc
ation, nam e of m e d ic
ation and d os ingins tru c
tions . T he
m e d ic
als taffm e m be rre pe ats this fore ac
hpatient re c
e ivingm e d ic
ation. T his is d one d u e to c
e ll
hou s e s havingthre e tiers and no e le vator, so am e d ic
ation c
art c
annot be u s e d . W he n c
om ple te d ,
the m e d ic
als taff m e m be r proc
e e d s to e ac
hc
e llhou s e and re ports to the c
e llhou s e offic
e r. T he
offic
e ris to e s c
ort the m e d ic
als taffto e ac
hc
e ll, ope n the m e als lot, and the m e d ic
als taffm e m be r
is to ide ntify the patient, who is to have wate r or othe r be ve rage for inge s tingthe m e d ic
ation.
M e d ic
al s taff is the n to ad m iniste r the m e d ic
ation and c
he c
k the patient
s m ou th for proper
inge s tion. T his is d one by way ofalarge wind ow in the c
e ll. W he n this proc
e s s is c
om ple te d , the
m e d ic
als taffm e m be rre tu rns to the m e d ic
ald e partm e nt and d oc
u m e nts on e ac
hpatient
s M e d ic
al
A d m inistration R e c
ord .
O bs e rvation of m e d ic
ation ad m inistration for c
e ll hou s e s R , S and T yield e d s om e s ignific
ant
iss u e s as follows .
1. U pon arrivalinto the firs t c
e llhou s e , no s e c
u rity s taffwas available to as s ist.
2. W e proc
e e d e d to the ne xt two c
e llhou s e s and s e c
u rity s taffwas not available ors aid the y
we re too bu s y to provide e s c
ort.
3. In re s pons e to qu e s tioningby the m onitor, the m e d ic
als taffm e m be rs tate d he was re qu ire d
to have as e c
u rity s taffm e m be rprovide e s c
ort.
4. W e proc
e e d e d bac
k to the firs t c
e llhou s e and the re was s tillno s e c
u rity s taffavailable ;we
waite d .
5. Finally, ac
e llhou s e offic
e rinqu ire d what we ne e d e d and the m e d ic
als taffm e m be rs tate d
pillpas s ,to whic
hthe offic
e rs tate d he was too bu s y. H e d id rad io as e rge ant for
Janu ary 2014
N orthern Rec epti

on C enter
P age 18
as s istanc
e and , afte r approxim ate ly 5-10 m inu te s , an offic
erc
am e into the c
e llhou s e to
provide e s c
ort.
6. W e proc
e e d e d to e ac
hc
e lld ooras ind ic
ate d by the m e d ic
als taffm e m be r. A t no tim e d id
the offic
e rope n the food s lot d oorand at no tim e d id the m e d ic
als taffm e m be rre qu e s t the
d oorbe ope ne d .
7. T he m e d ic
als taffm e m be rappropriate ly id e ntified e ac
hpatient and pas s e d the m e d ic
ation
e nve lope throu ghas m alls pac
e be twe e n the c
e lld oorand fram e .
8. T he patient wou ld re trieve the e nve lope , take the m e d ic
ation, ope n his m ou th for the
m e d ic
als taffm e m be rto obs e rve inge s tion and s lid e the e nve lope bac
k ou t.
9. W he n as ke d as to why the m e als lot d oorwas not be ingope ne d , the offic
e rs tate d he was
a rove r who was ins tru c
te d to re port to the c
e ll hou s e to as s ist with m e d ic
ation
ad m inistration and as are s u lt d id not have ke ys to the m e als lots . A d d itionally, whe n as ke d
why s e c
u rity s taffd id not pe rform the m ou thc
he c
ks , the m onitorwas inform e d appropriate
inge s tion was c
ons id e re d apart ofm e d ic
ation ad m inistration and , as s u c
h, am e d ic
als taff
fu nc
tion/re s pons ibility.
10. T he m e d ic
als taffm e m be rre pe ate d the proc
e s s u ntilc
om ple te d in c
e llhou s e s R and S and
we proc
e e d e d to T.
11. In c
e llhou s e T , the m e d ic
als taffm e m be rwe nt to the hou s ingu nit offic
e rwho was s itting
at his d e s k and s aid he d id not have tim e to provid e e s c
ort form e d ic
H e finally rad ioe d his s e rge ant bu t ne ve rprovide d any as s istanc
e . Finally, anothe roffic
er
e nte re d the c
e llhou s e to d e live rpape rs to the c
e llhou s e offic
e r. A s s he was le aving, s he
as ke d if s he c
ou ld he lp u s . W e told he r what we we re tryingto ac
c
om plish, and s he
im m e d iate ly s aid s he wou ld provide e s c
ort, whic
hs he d id.
12. M e d ic
ation ad m inistration forthre e c
e llhou s e s took 45-60m inu te s .
Laboratory
Laboratory s e rvic
e s are provide d throu ghthe U nive rs ity ofIllinois-C hic
c
e s m e d ic
alc
ontrac
tor provid e s 2.5 FT E s phle botom ist to d raw and pre pare
the s am ple s fortrans port to U IC . R e s u lts are e le c
tronic
k to the fac
ility, ge ne rally
within 24hou rs vias e c
u re fax line loc
ald e partm e nt. T he re were no re ports ofany
proble m s withthis s e rvic
e . W e are re c
om m e nd ing3.0FTE s forthis fac
ility.
Urgent/Emergent Care
W e fou nd that the re are no u s e fu llogs available to s e le c
t re c
ord s of patients be ings e nt ou t for
u rge nt ore m e rge nt proble m s . T he re is alogofinm ate inju ries and as e parate logofoffic
e rinju ries .
H owe ve r, the re is no c
u rre nt logofe m e rge nc
ies d e alt withons ite , so-c
alle d u rge nt proble m s , and
als o no logfore m e rge nc
y s e nd ou ts. W e were told that the y s om e tim e s list u rge nt proble m s as an
ad d -on to the s ic
kc
all. T his m ake s the m im pos s ible to d isc
e rn. H owe ve r, this partic
u lars trate gy is
not u s e d d u ringe ve nings ornights orwe eke nd s . In the only e m e rge nc
y logwe we re s hown the re
has be e n nothingliste d as oc
c
u rringe m e rge ntly s inc
e A u gu s t of 2013. O ne is the re fore le ft to
as s u m e that the re have be e n no e m e rge nc
ies ove rthe las t five m onths orthe re is ad isre gard forthe
re qu ire m e nt to trac
k the s e things. A program that d oe s not logand trac
k s e rvic
e s , inc
lu d ing
e m e rge nc
y s e rvic
e s , is u nable to e ffic
iently s e lfm onitorand s e lfc
orre c
t.
Janu ary 2014
N orthern Rec epti

on C enter
P age 19
P atient c
ontac
ts the offic
e rin the u nit who notifies m e d ic
als taff. N u rs e orm e d te c
hm ay go ons ite
to e valu ate the patient oras k the patient to be brou ght to the E R . W e we re told initially that the
nu rs e m ay re view the c
hart and d e c
id e that the patient s igns u p for s ic
kc
all. W he n qu e s tione d
abou t this, the D O N d e nied that the y d o this. T he re is anu rs e as s igne d e xc
lu s ive ly to u rge nt c
are .
Off-Site Emergencies
T he s e are trac
ke d on the s am e logas u rge nt c
are. C od e 3is m e d ic
ale m e rge nc
y and this inc
lu d e s
anyone the offic
e rfe e ls ne e d s im m e d iate re s pons e , not lim ite d to m an d own oru nre s pons ive ne s s .
T he re is ad e s ignate d c
od e te am e ac
hs hift to re s pond to the s e . R N s are as s igne d 24/7. T he re is an
on-c
alld oc
torand abac
ku pon-c
all. R N s are au thorize d to s e nd ou t c
ritic
ale m e rge nc
ies withou t
waiting for the phys ic
ian to c
all bac
k. T he y u s e St. Joe
s for e m e rge nc
y c
are . O the r m ore
c
om plic
ate d patients go to U nive rs ity ofIllinois (c
anc
e r, ne u ros u rge ry, H IV , he patitis C , e tc
). T he y
have aloc
ke d u nit forthe D O C patients . T he y have ac
ontrac
t to provide u pto 18ad m iss ions and
180ons ite c
ons u lts pe rm onth.
Nursing Telephone Urgent Care Log

It appe ars the y are only trac
kingthos e patients who are s e e n not allc
alls . T he y m ay be m iss ing
thos e who are told to s ign u pfors ic
kc
all, fore xam ple . T he logne e d s to be initiate d at the tim e of
the phone c
all, not in re tros pe c
t. D ay s hift has anu rs e as s igne d to this pu rpos e . O ff s hifts are
hand le d by whate ve rnu rs e is on d u ty.

W e u nd e rs tand that the polic
y that the R e c
e ption C e nte r ad he re s to is bas e d on patients be ing
proc
e s s e d throu ghthe re lative ly qu ic
kly. H owe ve r, as we le arne d , gre ate rthan 500 inm ate s had
be e n as s igne d to the R e c
e ption C e nte rforgre ate rthan 60d ays . Som e ofthe s e patients are in the
M SU , othe rs m ay be the re on writs and othe rs are d e laye d for othe r re asons . T he e nd re s u lt is
s im ilarto any othe rfac
ility;N R C m u s t have atrac
kings ys te m foralls c
es,
inc
lu d ingc
e d u re s .
W e re viewe d thre e re c
ord s ofpatients who we re refe rre d fors c
e s and two of
the thre e we re proble m atic
.
Patient #1
T his patient was s e e n at the U nive rs ity ofIllinois H e art C e nte r be c
au s e ofhis pac
e m ake r and a
prior c
ard iacablation proc
e d u re . H e was to be followe d u p two we e ks afte r his 6/6/13 visit.
H owe ve r, the re was no re c
ord ofthe follow u p appointm e nt havinge ve n be e n s c
he d u le d at the
tim e ofou rvisit. W e c
he c
ke d withthe U nive rs ity ofIllinois H e art C e nte rand he was not on the ir
books . T he re c
ord its e lfwas c
om ple te ly c
haotic
.
Patient #2
T his patient had ahistory ofc
anc
e rwithlu ngs u rge ry in 2002. O n 12/11/13, are qu e s t was m ad e
for him to have aC T s c
an and M R I ofthe lu ng. T his was approve d on 12/31/13. A s far as we
know, he we nt forthe te sts in e arly Janu ary. A t the tim e ofou rvisit the re we re no re ports in the
Janu ary 2014
N orthern Rec epti

on C enter
P age 20
c
hart and the re had be e n no follow u pbas e d on the re s u lts in the re ports . T his was pre s e nte d to the
N R C s taff.
T he s ite M e d ic
al D ire c
tor m u s t approve all s pe c
ialty re qu e s ts . A pprove d re qu e s ts the n go to
W e xford forc
olle gialre view whic
hoc
c
u rs we e kly. Fors tat c
ons u lts , the provide rc
an obtain the
te st, the n it goe s forretros pe c
tive re view. W e xford u s e s Inte rqu alc
rite ria, s o ifthe re qu e s t m e e ts
c
rite ria, it ge ts im m e d iate ly approve d by aU M nu rs e . O nly thos e that d on
t m eet c
rite riaare
d isc
u s s e d at c
olle gialre view. T he patient is notified in writingforallre qu e s ts that are d isapprove d .
Sc
he d u lingis d one at the tim e the re qu e s t is approve d . T he goalis u rge nt within 2we e ks , rou tine
within 1 m onth. T he age nc
y m e d ic
ald ire c
torc
an ove rru le d isapprovalby the ve nd or. T he re are
thre e le ve ls ofappe albe fore this le ve l. T he re is a5-d ay tu rnarou nd tim e forappe als . T he d e nials
are trac
ke d by the Q I c
om m itte e .
Infirmary
T he re is an are aat N R C c
ons tru c
te d as an infirm ary;howe ve r, the are ahas ne ve rbe e n s taffe d and
u tilize d as an inpatient infirm ary. T he are ais c
u rre ntly be ingu s e d form e ntalhe althobs e rvations
and s e c
u rity fu nc
tions . N R C inm ate s re qu iringinfirm ary plac
e m e nt are hou s e d in the State ville
C orre c
tionalC e nte rm e d ic
ald e partm e nt infirm ary, whic
his s taffe d 24hou rs pe rd ay, s e ve n d ays
pe rwe e k.
T he re we re fou rN R C patients ad m itte d to the Stateville infirm ary at the tim e ofou rvisit. A llwe re
c
ons id e re d c
hronic
ad m iss ions who we re hou s ed in the infirm ary longte rm . B y polic
y, the s e
patients re qu ire aphys ic
ian visit onc
e we e kly;howe ve r, the N R C M e d ic
alD ire c
torwas rou nd ing
on the s e patients at le as t thre e tim e s awe e k at the tim e ofou rre view. C ons id e ringthe bac
klogand
d aily s taffings hortage s in the R e c
e ption C e nte r, it was e vid e nt that the M e d ic
alD ire c
tor
s tim e
wou ld be be tte rs pe nt whe re it was m os t ne e d e d .
W e re viewe d the he althre c
ord s ofallthe N R C patients hou s e d in the State ville infirm ary. T he
phys ic
ian
s note s we re e s s e ntially ille gible in ne arly e ve ry ins tanc
e . D e s pite the fre qu e nc
y of
phys ic
ian visits , we fou nd that the c
are was inad e qu ate in thre e ofthe fou r re c
ord s as d e s c
ribe d
be low.
Patient #1
T his patient was ad m itte d on 1/16/14followings u rge ry to re pair inju ries s u s taine d by agu ns hot
wou nd to the abd om e n. T he M e d ic
alD ire c
tor has be e n s e e ingthe patient at le as t thre e tim e s a
we e k and his note s are alm os t c
om ple te ly ille gible . T he vitals ign flow s he e t had not be e n fille d
ou t s inc
e 1/25/14, thou ghvitals are to be m e as u re d at le as t we e kly pe rpolic
y. T he m os t re c
e nt s e t
ofvitals c
ontaine d in the re c
ord as ofthe tim e ofou rvisit on 2/24we re d oc
u m e nte d in anu rs e
s
note on 2/14;the patient
s blood pre s s u re was noted to be qu ite e le vate d at 156/111u pon his re tu rn
from ane u ros u rge ry appointm e nt. It was not re pe ate d .
Patient #2
T his patient was ad m itte d to the infirm ary on 1/27/14d ire c
tly from D u P age C ou nty H os pitalwith
paraple giare s u ltingfrom agu ns hot wou nd to the thorac
ics pine . H e was on two blood thinne rs
(C ou m ad in and Love nox)and his he m oglobin had d roppe d s ignific
antly from 11.6on
Janu ary 2014
N orthern Rec epti

on C enter
P age 21
1/28 to 9.7 on 2/17. It was im pos s ible to te llif the phys ic

ian had any plans to inve s tigate this
fu rthe r, as we c
ou ld not d e c
iphe rhis note s .
Patient #3
T his is a63-ye ar-old m an with ahistory of s troke re s u ltingin le ft s id e d he m iple giawho was
ad m itte d to the infirm ary on 9/27/13. H e als o has c
oronary arte ry d ise as e withahistory ofbypas s
s u rge ry, d iabe te s , and hype rte ns ion. D e s pite the s e c
hronicillne s s e s , he has not had any blood work
s inc
e his ad m iss ion, nord oe s he appe arto be e nrolle d in the c
hronicc
are program .
Dental Program
Executive Summary
O n M ay 19and 20, 2014, ac
om pre he ns ive re view ofthe d e ntalprogram at N R C was c
om ple te d .
Five are as ofthe program we re ad d re s s e d , inc
lu d ing:
1.
2.
3.
4.
5.
Inm ate s ac
c
e s s to tim e ly d e ntalc
are
T he qu ality ofc
are
T he qu ality and qu antity ofthe provide rs
T he ad e qu ac
y ofthe phys ic
alfac
ilities and e qu ipm e nt d e vote d to d e ntalc
are
T he ove ralld e ntalprogram m anage m e nt
T he followingobs e rvations and find ings are provid e d .

T he c
linicits e lfc
ons ists ofas ingle c
hairand u nit in arathe rs m allroom . T wo c
onne c
te d c
los e ts ize d room s hou s e the d e ntallaboratory and s te rilization are a, and are u s e d for the s torage of
ins tru m e nts and s u pplies . T he c
hairand u nit are ove r20ye ars old and s how we arand te ar. Som e
c
orros ion, fad ingand ru s t is e vid e nt. C abine try is s im ilarly old and worn.
e ption and C las s ific
ation C e nte r (N R C ) is the m ajor re c
e ption c
e nte r for the
Illinois D e partm e nt of C orre c
tions . Se ve ral hu nd re d inm ate s a m onth are m ove d throu gh the
sc
re e ninge xam ination proc
e s s , inc
lu d ingad e ntals c
re e ninge xam ination. T he d e ntals c
re e ning
e xam ination c
ons ists of a ve ry c
u rs ory m irror and d ire c
t view e xam ination of the intra-oral
s tru c
tu re s , apane lips e rad iograph, and an ins u ffic
ient and s ke tc
hy he alth history. T he te eth are
c
harte d forc
aries and pathology from the m irrorexam ination and the pane lips e rad iograph. T he
inm ate s tand s d u ringthe e xam ination and lightingis poor. T he s oft tiss u e and e xtra-orale xam is
inad e qu ate and alm os t none xiste nt. A s are c
e ption c
e nte r, this s hou ld be the m os t thorou ghpart of
the e xam ination. E arly d e te c
tion ofs oft tiss u e pathology is c
e ntralto s u c
c
e s s fu ltre atm e nt.
T he pane lips e rad iographs are take n two at atim e in the s am e s m allroom . T he m ac
hine s are abou t
fou rfe e t apart and x-rays ofte n take n s im u ltane ou s ly. T he inm ate s we arno le ad apron prote c
tion.
N o s igns are poste d warningof rad iation haz ard s . T his is ad ire c
t violation of rad iation s afe ty
s tand ard s .
T he N R C is are c
e ption c
e nte rforthe ID O C and c
ontains ad e d ic
ate d are aforthe d e ntals c
re e ning
e xam ination. T his are ac
ons ists ofthre e s m allroom s whic
hare ad e qu ate to m e e t this ne e d .
Janu ary 2014
N orthern Rec epti

on C enter
P age 22
A m ajorare aofc
onc
e rn is that c
om pre he ns ive c
are was provide d withou t ac
om pre he ns ive intra
and e xtra-oral e xam ination and we ll-d e ve lope d tre atm e nt plan. A d oc
u m e nte d s oft tiss u e
e xam ination was not provide d nor was pe riod ontalas s e s s m e nt part ofthe tre atm e nt proc
ess. N o
bite wingnorperiapic
alrad iographs we re e ve rpart ofthe provid e d c
are . H ygiene c
are was ne ve r
available nor we re oralhygiene ins tru c
tions e ve r d oc
u m e nte d . R e s torations we re provide d from
the inform ation from apane lips e rad iograph. T his rad iographis not d iagnos ticforc
aries .
M any, m any re c
ord e ntries provide d pain m e d ic
ation and /or antibiotic
s with no d oc
u m e nte d
e xam ination ord iagnos is. T he re is no ind ic
ation why the y we re pre s c
ribe d .
onc
e e d from a
d oc
u m e nte d d iagnos is. T he re as on for e xtrac
ord e ntry. In none of
the re c
ord s e xam ine d was a d iagnos is or re as on for e xtrac
tion d oc
u m e nte d . D oc
u m e ntation,
ove rall, was ve ry poor.
A d d itionally, antibiotic
s we re pre s c
ribe d prophylac
tic
ally afte re ve ry e xtrac
tion withno d iagnos is
orind ic
ation why the re we re provide d . T his is not as tand ard ofc
are .
ons tru c
te d as afinals te pin the s e qu e nc
e ofc
are d e live ry inc
lu d e d in
the c
om pre he ns ive c
are proc
e s s . A re c
ord re view re ve ale d that all partial d e ntu re s proc
eed ed
withou t ac
om pre he ns ive e xam ination and tre atm e nt plan. P e riod ontalas s e s s m e nt and tre atm e nt
was not provide d . O ralhygiene ins tru c
tions we re ne ve r inc
lu d e d . It was alm os t im pos s ible to
d e m ons trate that all fillings and e xtrac
tions we re c
om ple te d prior to im pre s s ions . P e riod ontal
he althwas ne ve rd oc
u m e nte d .
A t N R C , s ic
kc
allis ac
c
e s s e d throu ghthe inm ate re qu e s t form . E m e rge nc
ies c
an be c
alle d in by
s taffand are s e e n that d ay. T he re was no re altriage s ys te m in plac
are ne e d s ,
i.e ., pain and s we lling. Inm ate s withu rge nt c
are c
om plaints from the re qu e s t form ofte n took s ix
to s e ve n d ays to be s e e n by the d e ntist orothe r appropriate he althc
are provid e r. T he s e inm ate s
s hou ld be s e e n within 24-48hou rs from the d ate ofthe re qu e s t form .
In none ofthe re c
ord s re viewe d was the SO A P form at be ingu s e d . T re atm e nt was provid e d with
little orno inform ation ord etailpre c
e d ingit. R e c
ord e ntries d id not inc
lu d e c
linic
alobs e rvations
ord iagnos is to ju s tify tre atm e nt. A s the ove rwhe lm ingm ajority ofinm ate s at the N R C are the re
forave ry s hort tim e , the e m phas is at the N R C s hou ld be ad d re s s ingu rge nt c
are ne e d s in atim e ly
m anne r.
Faile d appointm e nts we re as e riou s proble m at the N R C . A rate as highas 43% was fou nd . T his is
an u nac
c
e ptably highpe rc
ts re alm ism anage m e nt ofthe u rge nt c
are triage and
sc
he d u lingproc
ess. B ec
au s e m os t inm ate s are the re s u c
h a s hort tim e , by the tim e the y are
sc
he d u le d to be s e e n, the y have trans fe rre d to anothe rins titu tion.
M e d ic
alc
au tions and c
als taff prior to d e ntal
u m e nte d in the he althhistory s e c
ord and re d
flagge d to bringthe m to the im m e d iate atte ntion ofthe provide r. T he pre c
au tions take n s hou ld
Janu ary 2014
N orthern Rec epti

on C enter
P age 23
als o be we lld oc
u m e nte d in the re c
ord e ntry. A ntic
oagu lant the rapy is agood be llwe the rc
ond ition
to trac
k the above . N one ofthe re c
ord s e xam ine d we re re d flagge d forantic
oagu lant the rapy.
Inm ate [redacted] was on C ou m ad in the rapy and had tooth#19e xtrac
te d withou t m e ntion in the
d e ntalre c
ord . N o pre c
au tions we re take n ord oc
u m e nte d priorto the e xtrac
tion.
Inm ate [redacted] was on P lavix anti-c
oagu lant the rapy and had te e the xtrac
te d and not
ad d re s s e d in the d e ntalre c
ord . W he n as ke d , the d e ntist s aid it was m anage d c
orre c
tly bu t not
d oc
u m e nte d . B lood pre s s u re s s hou ld , at the le as t, be take n on patients withahistory of
hype rte ns ion. W he n as ke d , the c
linic
ian ind ic
ate d that s he d oe s not rou tine ly take blood
pre s s u re s on the s e patients .
T he s te rilization are ais in as m allc
los e t-like room ad jac
e nt to the c
linic
. It was rathe r u nke m pt
and c
lu tte re d . T he s te rilization flow from d irty to ste rile was not in plac
e . T he u ltra-s onicu nit was
be twe e n the s ink and the s te am au toc
lave . Flow s hou ld be from u ltra-s onic
, to s ink, to pac
kaging
are a, to au toc
lave , to storage . A ls o, the re was not a biohaz ard warning s ign pos te d in the
s te rilization are a.
Safe ty glas s e s we re not always worn by patients d u ringtre atm e nt. N o rad iation haz ard s igns we re
poste d in the are awhe re x-rays are take n.

N R C has a d e ntal s taff of one fu ll-tim e d e ntist, one 20-hou r part-tim e d e ntist, two fu ll-tim e
as s istants , and afu ll-tim e hygienist. T his s hou ld be ad e qu ate to provide m e aningfu ld e ntals e rvic
es
for N R C
s 2000 inm ate s . D r. M itc
he llis e m ploye d by the ID O C and allthe re s t ofthe s taffare
c
ontrac
es.
C P R trainingis c
e s s ary lic
e ns ingis on file , and D E A nu m be r is on file
forthe d e ntist.
C hris Lu c
e y is als o an as s istant at State ville C C . The d e ntists from State ville are available to he lp
at the N R C whe n ne e d e d . In fac
t, the y are re s pons ible form os t ofthe s c
re e ninge xam inations d one
at the N R C .
Staffingis ad e qu ate to m e e t the ne e d s ofthe N R C .

T he c
linicc
ons ists ofas ingle c
hairand u nit whic
his ove r20ye ars old and s howingwe arand te ar.
Som e c
orros ion, fad ingand ru s t is e vid e nt. C abine try is s im ilarly old and worn. T he c
om pre s s or
is in good c
ond ition. H and ins tru m e nts are in good c
ond ition and ad e qu ate . T he x-ray u nit is old
bu t in good re pair. H and piec
e s are old and m any are not fu nc
tioning.
Janu ary 2014
N orthern Rec epti

on C enter
P age 24
T he c
linicits e lfc
ons iste d ofas ingle u nit s itu ate d in as m allbu t ad e qu ate s pac
e s . Fre e m ove m e nt
arou nd e ac
hu nit is ac
c
e ptable P rovide rand as s istant have ad e qu ate room to work. T he re are two
c
los e t-s ize d room s ad jac
e nt to the c
linicforstorage , the d e ntallab, and forste rilization. O ve rall,
the c
linicwas we lle nou gh e qu ippe d and D r. B rown fe lt alle qu ipm e nt was in good s hape and
fu nc
tional. She e xpre s s e d s om e d iffic
u lty in ge ttinge qu ipm e nt re paire d d u e to alac
k offu nd s and
ad m inistrative s u pport.
T he are aand room s whe re the s c
re e ninge xam s are provide d s hou ld have c
hairs and be be tte r
lighte d . T he pane lips e x-ray u nits are old bu t s e e m to fu nc
tion O K .
Recommendations:
1. T he c
hair and u nit s hou ld be c
ons id e re d for re plac
e m e nt in the ne ar fu tu re . H and piec
es
s hou ld be re paire d .
2. T he e xam ination room s forthe s c
re e ninge xam s s hou ld be be ttere qu ippe d . P atients s hou ld
be s e ate d and lightings hou ld be ad e qu ate forthe e xam .
Sanitation, Safety, and Sterilization

hniqu e s and proc
e d isinfe c
tion was
tants we re be ing
u s e d . P rote c
tive c
ove rs we re u tilize d on m any ofthe s u rfac
es.
A n e xam ination of ins tru m e nts in the c
abine ts re ve als that m os t we re properly bagge d and
s te rilize d . T he intake s c
re e ninge xam ination m irrors we re bagge d and s te rilize d in bu lk. A fte r
obs e rvinghow the y are m anage d d u ringthe e xam ination proc
e s s , whic
hwas u ns anitary, pe rhaps
is wou ld be be s t to bagthe m ind ivid u ally. A llhand piec
T he s te rilization are ais in as m allc
los e t-like room ad jac
e nt to the d e ntalc
linic
. It is rathe ru nke m pt
and c
lu ttere d . It has inad e qu ate work s pac
e to m aintain prope r ste rilization flow from d irty to
s te rilize d to storage . T he u ltras onicc
le ane rs its be twe e n the s ink and the au toc
lave . T he re was not
abio haz ard labe lpos te d in the s te rilization are a.
Safe ty glas s e s we re not always worn by patients . E ye prote c
tion is always ne c
e s s ary, forpatient
and provide r.
I als o obs e rve d that no warnings ign was pos te d whe re x-rays we re be ingtake n to warn pre gnant
fe m ale s ofpos s ible rad iation haz ard s .
Recommendations:
1. T hat the s te rilization are abe ne ate ne d and e ve ry atte m pt m ad e to c
orre c
t the s te rilization
flow. It m ay m e an re c
onfigu ringthe s pac
e and the s torage u tilization the re in.
4. A warnings ign be poste d in the x-ray are ato warn ofrad iation haz ard s , e s pe c
ially pre gnant
fe m ale s .
Janu ary 2014
N orthern Rec epti

on C enter
P age 25

I looke d bac
k two ye ars and fou nd the s te rilization logs to be in plac
e . T he y s howe d that
au toc
laving was ac
c
om plishe d we e kly and d oc
u m e nte d . T he y u tilize the Sc
he in M axi-te s t
biologic
al vial s ys te m with the inc
u bator in the s te rilization are a. N o ne gative re s u lts we re
obtaine d . I d id obs e rve that no biohaz ard warnings ign was poste d in the s te rilization are a.
Comprehensive Care
tive tre atm e nt c
A s are c
e ption c
e nte r, only ave ry s m allpe rc
e ntage ofthe popu lation is ac
tu ally d e s ignate d to this
ins titu tion. It re pre s e nts abou t 10% ofthe popu lation at the N R C , and the s e inm ate s are hou s e d in
the m inim u m -s e c
u rity u nit. T his is the popu lation that s hou ld be c
ons id e re d for c
om pre he ns ive
c
are . T he y willbe the re longe nou ghto be e ligible and available forthis le ve lofc
are . W ith90%
ofthe popu lation as ve ry s hort-term s c
re e ningand c
las s ific
ation inm ate s , this is whe re the vas t
m ajority ofd e ntalre s ou rc
e s s hou ld be d ire c
te d at the N R C . T his popu lation ne e d not be c
ons id e re d
for rou tine c
are . T he y will re c
e ive that le ve lof c
are at the ir d e s ignate d ins titu tion. T he m ain
e m phas is at the N R C s hou ld be ad d re s s inge m e rge nc
ies and u rge nt c
are and provid ingthe
sc
re e ninge xam inations . A c
c
e s s to c
are throu ghthe s ic
kc
allproc
e s s be c
om e s allim portant. A ll
c
om plaints ofpain or s we llings hou ld be s e e n within 24-48 hou rs , that is, the ne xt workingd ay
from re c
e ipt ofthe c
om plaint.
B ec
au s e ofthe rapid tu rnove r of inm ate s , m os t ofthe re c
ord s re viewe d we re ve ry re c
e nt, and I
foc
u s e d on inm ate s who re c
e ive d rou tine ope rative d e ntistry, that is, pe rm ane nt fillings. M any, if
not m os t, ofthe s e inm ate s we re from the trans ient, s hort-te rm popu lation.
are proc
eed
from a thorou gh, we ll d oc
u m e nte d intra and e xtra-oral e xam ination and a we ll-d e ve lope d
tre atm e nt plan, to inc
lu d e allne c
e s s ary d iagnos ticx-rays . A re view of10 re c
ord s re ve ale d that
no c
om pre he ns ive e xam ination was pe rform e d and no tre atm e nt plans d e ve lope d . N o
e xam ination of s oft tiss u e s or pe riod ontal as s e s s m e nt was part of the tre atm e nt proc
ess. N o
bite wingorpe riapic
alx-rays we re e ve rpart ofthe tre atm e nt. H ygiene c
are was ne ve rprovid e d
as part of the tre atm e nt. O ralhygiene ins tru c
tions we re ne ve r d oc
u m e nte d . R e s torations we re
provid e d from the inform ation from the panore x rad iograph. T his rad iographis not d iagnos ticfor
c
aries .
M any, m any re c
ord e ntries provide d pain m e d ic
ation and /or antibiotic
s with no d oc
u m e nte d
e xam ination or d iagnos is. T he re was no ind ic
ation why the y we re provide d . A n e xam ple was a
re c
ord e ntry from 3/24/14. It re ad :R /E e xam ;R x Ibu profe n 400m gx 30;N .V . am algam s #
s 29,
30, 31.
M any, m any re c
ord e ntries als o we re n/s (no s how)and /or re s c
he d u le . W he n as ke d , the d e ntist
s aid patients we re re s c
he d u le d ord id not s how foravariety ofre as ons . T he s e inc
lu d e d no as s istant,
inm ate trans fe rre d , s e c
u rity iss u e s , qu arantine , and the inm ate ju s t d id not s how. T his iss u e is
ad d re s s e d in the faile d appointm e nt s e c
tion ofthis re port.
Janu ary 2014
N orthern Rec epti

on C enter
P age 26
Recommendations:
are be provide d only from awe ll-d e ve lope d and d oc
u m e nte d
tre atm e nt plan.
2. T he tre atm e nt plan be d e ve lope d from athorou gh, we ll-d oc
lu d e a pe riod ontal as s e s s m e nt and d etaile d e xam ination of all s oft
tiss u e s .
3. In allc
as e s , that appropriate bite wingorpe riapic
aries .
4. H ygiene c
ess.
5. T hat c
e s and d e ntal
prophylaxis.
u m e nte d .
7. P rovid e c
om pre he ns ive , rou tine c
are only to the d e s ignate d , longte rm popu lation.
Dental Screening
W e re viewe d 10 inm ate d e ntalre c
e ption c
e nte rs within the
pas t 60d ays to d ete rm ine ifs c
e ption c
e nte rand apanoram icxray was take n. (A d m inistrative D ire c
tive 04.03.102page 2, A C A Stand ard 4-4360).
T he re c
e ption s c
re e ningc
ons ists of s e ve rals tations in line ar s u c
c
e s s ion. Inm ate s go from one
s tation to the ne xt u ntilthe y are c
om ple te d . M e d ic
al, m e ntalhe alth, and d e ntalare allinc
lu d e d as
s tations in this proc
ess.
T he d e ntals c
re e ninge xam ination c
ons ists ofac
u rs ory m irrorand d ire c
t view e xam ination ofthe
intra-orals tru c
tu re s , apane lips e rad iograph, and ave ry s ke tc
hy he alth history. T he te e th are
c
harte d forpathology from the d ire c
t e xam ination and from the pane lips e x-ray. O ne d e ntist was
the re to s c
re e n ove r70inm ate s . I was told the re are ofte n m ore . T he inm ate was s tand ingwhile
be inge xam ine d . T he e xam ine r
s hand s ne ve re nte re d the oralc
avity. T he e xam was ve ry qu ic
kly
d one , takingabou t 15s e c
ond s . Lightingwas poor. M irrors c
am e from abu lk pac
kage ofs te rilize d
m irrors from the N R C d e ntalc
linic
. T he pane lips e x-rays are take n two at atim e in the s am e
s m allroom . T he m ac
hine s are abou t thre e to fou rfe e t apart. T he y are ofte n take n s im u ltane ou s ly.
T he inm ate s we arno le ad apron prote c
tion, norare the re any s igns warningofrad iation haz ard .
T he rad iographs are take n and d e ve lope d by inm ate s from the m inim u m s e c
u rity u nit, as ate llite
ofN R C . T he y als o re load the c
as s e tte s that hold the film . T he film s are d e ve lope d , d ate d and
labe le d withinm ate inform ation. T he y m ake it to the m e d ic
alre c
ord from the re .
Se ve ralare as ofc
onc
e rn are e vid e nt.
V e ry little are ad isinfe c
tion or c
linic
ian hygiene took plac
e be twe e n patients . Glove s we re not
c
ons iste ntly c
hange d be twe e n patients . E ve n thou ghthe y only he ld the m irror hand le and ne ve r
e nte re d the inm ate
s m ou th, glove s s hou ld be c
hange d be twe e n patients .
M irrors we re grabbe d haphaz ard ly from the pile in the ope ne d bu lk bag.
A llin all, the e xam is inad e qu ate ly c
u rs ory. Inappropriate ly, m any ins titu tions u s e this e xam as a
Janu ary 2014
N orthern Rec epti

on C enter
P age 27
c
om pre he ns ive e xam from whic
h tre atm e nt is d e live re d . T he s oft tiss u e e xam s hou ld be m ore
thorou gh.
Inm ate s are provide d no prote c
tion from rad iation while the pane lips e is be ingtake n. T he y s tand
thre e to fou rfe e t from e ac
hothe rwhile x-rays are take n s im u ltane ou s ly.
C aries are c
harte d on the d e ntalre c
ord from the pane lips e x-ray.
T he he althhistory is s ke tc
hy and qu ic
kly take n. C ond itions that m ight re qu ire m e d ic
alc
ons u ltation
prior to tre atm e nt, e .g., anti-c
oagu lant the rapy, are not re d flagge d to c
aptu re the im m e d iate
atte ntion ofthe c
linic
ians .
Recommendations:
1. P rovid e am ore thorou ghs oft tiss u e e xam ination. T his is the m os t im portant part ofthe
sc
re e ninge xam and s hou ld inc
lu d e intra-oralpalpation and awe ll-lighte d e xam ination of
alls oft tiss u e s u rfac
es.
2. N ote pathology s e e n on the pane lips e rad iograph. D o not d iagnos e s m allc
ariou s le s ions
from this rad iograph.
3. D o not provide c
om pre he ns ive rou tine c
are from this e xam ination. T his is as c
re e ning
e xam ination.
4. D o not take the pane lips e rad iographs im u ltane ou s ly withinm ate s s tand ingne xt to e ac
h
othe r. T his is ad ire c
t violation ofrad iation s afe ty. P rovid e prote c
tive le ad apron c
ove rage
to the inm ate re c
e ivingthe x-ray.
5. P lac
e s ignage in the rad iographare awarningofrad iation haz ard .
6. Ind ivid u ally bagand s te rilize the m ou thm irrors oru s e d ispos able m irrors .
7. W as hhand s and c
hange glove s be twe e n patients .
8. T ake am ore thorou gh he alth history and re d flag he alth iss u e s that re qu ire m e d ic
al
atte ntion priorto d e ntaltre atm e nt.
Extractions
ord s ofd e ntals u rgic
alinm ate s to d e term ine if:
1. R e c
e nt pre -ope rative rad iographs re fle c
tingthe c
u rre nt c
ond ition oftoothe xtrac
te d . X -rays
m u s t be ofd iagnos ticvalu e s howingapic
e s ofte e th.
2. R e as on fore xtrac
tion is d oc
u m e nte d .
3. C ons e nt form is u s e d and s igne d by the patient.
e e d s from awe ll-d oc
u m e nte d
d iagnos is. In none ofthe re c
ord s e xam ine d was ad iagnos is or re ason for e xtrac
tion inc
lu d e d as
part ofthe d e ntalre c
ord e ntry. D oc
u m e ntation was ve ry poor.
A d d itionally, antibiotic
s we re provide d to e ve ry patient pos t-ope rative ly who had a d e ntal
e xtrac
tion, e ve n ifnot ind ic
ate d . T his is not as tand ard ofc
are noran appropriate u s e ofantibiotic
s.
It s hou ld c
e as e im m e d iate ly. T he re is no re as on to give antibiotic
s rou tine ly afte re xtrac
tions . T he y
s hou ld be pre s c
ribe d appropriate ly and only whe n ind ic
ate d .
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P age 28
Recommendations:
1. A d iagnos is orare as on forthe e xtrac
tion be inc
be s t ac
c
ially fors ic
kc
alle ntries .
kingin m os t d e ntale ntries obs e rve d . T oo ofte n, the
d e ntal re c
ord inc
lu d e s only the tre atm e nt provid e d with no e vid e nc
e as to why that
tre atm e nt was provide d .
2. P rovid e antibiotic
s appropriate ly from ad iagnos is and only whe n ind ic
ate d .
W e re viewe d d e ntal re c
ord s of five patients having re c
e ive d c
om ple te d partial d e ntu re s to
d e te rm ine if re s torative proc
e d u re s we re c
ation of partiald e ntu re s (68M E D -12D e ntalSe rvic
e s D . P rovision ofD e ntalC are page 4#5and #9).
s s hou ld proc
e e d only afte r allothe rtre atm e nt re c
ord e d on
om ple te d . T he pe riod ontal, ope rative and orals u rge ry ne e d s alls hou ld be
ad d re s s e d firs t.
I was able to find thre e patients withpartiald e ntu re s c
ons tru c
te d orbe ingc
ons tru c
te d . T he partial
d e ntu re s are c
ons tru c
te d throu gh State ville C C , the pare nt ins titu tion. A c
om pre he ns ive
e xam ination and tre atm e nt plan was ne ve r part ofthe tre atm e nt proc
e s s . P e riod ontalas s e s s m e nt
and tre atm e nt was not provide d in any of the re c
ord s . B e c
au s e the re is no c
om pre he ns ive
e xam ination orany tre atm e nt plans d e ve lope d and d oc
u m e nte d in any ofthe re c
ord s , it is alm os t
im pos s ible to as c
e rtain ifallne c
e s s ary c
are , inc
lu d ingope rative and /ororals u rge ry tre atm e nt, is
c
Recommendations:
1. A c
om pre he ns ive e xam ination and we ll d e ve lope d and d oc
inc
lu d ingbite wingand /or periapic
alrad iographs and pe riod ontalas s e s s m e nt, pre c
e d e all
c
are , inc
s.
e s s and that the
c
Dental Sick Call

Inm ate s ac
c
ess c
are viaan inm ate re qu e s t form . E m e rge nc
ies c
an be c
alle d in by s taff and D r.
B rown s ays s he atte m pts to s e e the m that d ay. Inm ate re qu e s ts are logge d into alarge bou nd le d ge r
ind ic
atingc
om plaint, d ate of re qu e s t and d ate of appointm e nt. T he re qu e s ts are re viewe d and
s om e what prioritize d by the u rge nc
y natu re ofthe re qu e s t. T his is not am e aningfu ltriage s ys te m .
In none ofthe re c
ord s re viewe d was m e ntion m ad e ofthe inm ate c
om plaint. N o obs e rvations we re
note d . N o as s e s s m e nts we re m ad e . T he only e ntry is the provide d tre atm e nt. O fte n the tre atm e nt
was pain m e d ic
ation orantibioticwithno d oc
u m e ntation as to why the y we re pre s c
ribe d .
I e xtrapolate d figu re s from this O ffe nd e rR e qu e s t Log. O n ave rage , 12re qu e sts are re c
e ive d by
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P age 29
the d e ntalc
linicd aily. O fthos e , abou t 50% are withc
om plaints ofpain, s we lling, ortoothac
he s .
Lookingat thos e re qu e sts forFe bru ary, M arc
h, and A pril, the ave rage appointm e nt d ate was s e ve n
d ays from the d ate ofthe re qu e s t. E ve ry e ffort s hou ld be m ad e to e valu ate the s e inm ate s in pe rs on
within 24-48hou rs from re c
e ipt ofthe re qu e s t form .
ord s re viewe d was the SO A P form at be ingu s e d . A s are s u lt, tre atm e nt
was u s u ally provid e d withlittle inform ation ord etailpre c
e d ingit. Sic
kc
allre c
ord e ntries d id not
inc
lu d e c
linic
alobs e rvations or d iagnos is to ju s tify provid e d tre atm e nt. T he u s e of the SO A P
form at wou ld ins u re that awe ll-d e ve lope d d iagnos is wou ld pre c
e d e alltre atm e nt. R ou tine c
are
was not provide d at the s e appointm e nts .
Recommendations:
kc
s
c
hief c
om plaint is re c
d iagnos is pre c
2. D e ve lopare qu e s t/sic
kc
alls ys te m that ins u re s that inm ate s c
om plainingofpain/swe lling/
toothac
he s are s e e n by aprovide r and e valu ate d within 24-48 hou rs from re c
e ipt of the
re qu e s t.
Treatment Provision
Inm ate s re qu e s t c
are viathe inm ate re qu e s t form e m e rge nc
y s lips . T he C M T c
olle c
ts the m at the
u nits and pu ts the m in abox ou ts id e of d e ntal. T he re qu e s t form s the m s e lve s are triage d and
appointm e nts prioritize d bas e d on the u rge nc
y natu re of the re qu e s t. N o form altriage s ys te m
e xists .
Inm ate s c
are viathe re qu e st form or ifthe y fe e lthe ir ne e d is an e m e rge nc
y by
c
ontac
tingins titu tion s taff, who the n c
allthe d e ntalc
sc
om plaint. D r. B rown
s aid s he m ake s e ve ry atte m pt to s e e thos e patients that d ay. E xtrapolatingfigu re s from the O ffe nd e r
R e qu e s t Log, I d eterm ine d that the ave rage wait tim e for inm ate s with c
om plaints of
pain/swe lling/toothac
he was s e ve n d ays from the tim e ofthe s u bm iss ion ofthe re qu e s t form u ntil
the y we re s c
he d u le d . A re view ofs e ve ralre c
ord s re ve ale d that the y we re ofte n s e e n late rthan that
d u e to the highno s how and re s c
he d u le rate . M any ofthe inm ate s had trans fe rre d ou t ofN R C by
the tim e ofthe irappointm e nt. T he d e ntalprogram at N R C s hou ld be bas ic
ally as ic
kc
allprac
tic
e.
A d d re s s ingu rge nt c
are c
om plaints s hou ld be aprim ary m iss ion of the d e ntalprogram at this
ins titu tion. T he y s hou ld be s e e n in a tim e ly and e xpe d itiou s m anne r and the ir c
om plaints
ad d re s s e d .
R ou tine c
are is ac
c
e s s e d from the re qu e s t form . T he y are s e e n within 14d ays and tre atm e nt s tarte d .
T he re is no waitinglist and re s c
he d u le s are s e e n within 14d ays . A lthou ghthe s ys te m s e e m s fair
and e qu itable , this c
are s hou ld be available to the d e s ignate d popu lation at the M SU only. O nly
palliative c
are ne e d be provide d to the orientation popu lation. T his grou pre pre s e nts ove r90% of
the popu lation.
Recommendations:
1. D e ve lopas ys te m s u c
hthat u rge nt c
are c
om plaints (pain, s we lling, toothac
he s )are s e e n
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P age 30
in pe rs on for e valu ation and triage by the ne xt workingd ay, and that c
are be provide d
e xpe d itiou s ly. O the rwise , the s e inm ate s are trans fe rre d and gone iftoo m u c
htim e e laps e s .
T his s hou ld be aprim ary m iss ion at N R C .
2. P rovid e rou tine c
om pre he ns ive c
are to the d e s ignate d M SU popu lation only.
T he N R C is inc
lu d e d in the State ville O ffe nd e r O rientation M anu al. It ad d re s s e s the orientation
sc
re e ninge xam , bu t in little d e tail. O nly that the inm ate willre c
e ive one as s oon as pos s ible . It
e xplains how to ac
c
e s s e m e rge nc
yc
are bu t d oe s not e xplain the re qu e s ts form s ys te m forac
c
e s s ing
u rge nt and rou tine c
are . It d e s c
ribe s the hou rs of operation, partiald e ntu re s , appointm e nts and
c
le anings.
Recommendations:
1. Ins u re that the orientation m anu ald e s c
ribe s fu lly and ac
c
u rate ly how inm ate s c
an ac
c
ess
bothu rge nt and rou tine c
are viathe inm ate re qu e s t form s ys te m .

T he Ins titu tional D ire c
tive s and polic
ies are m aintaine d in the A s s istant W ard e n
s offic
e at
State ville C C and apply to boththe N R C and Stateville . I willre view the m at State ville C C .
Failed Appointments
It be c
am e qu ic
kly appare nt that faile d appointm e nts we re are alproble m at the N R C . To gets a
m ore ac
c
u rate pic
tu re ofthe proble m , I c
hos e the 23 d ays ofappointm e nts in M arc
hand A pril.
T his s e e m e d to re pre s e nt an ac
c
u rate s am ple . For thos e 23 d ays , the re we re 409 s c
he d u le d
appointm e nts . O fthat nu m be r, 165 patients we re ac
tu ally s e e n. T his re pre s e nts only 40% ofthe
patients who we re s c
he d u le d . T he re s t we re re s c
he d u le d , trans fe rre d , orno s howe d . O fthe patients
who c
ou ld have be e n s e e n (s c
he d u le d m inu s trans fe rre d ), 43% faile d the irappointm e nt. T he 20%
who we re trans fe rre d re fle c
t the tim e from whe n the y we re logge d into the appointm e nt book to
whe n the y we re s c
he d u le d and the u nd e rs tand able highand rapid tu rnove rrate at the N R C .
T he s e are alarm ingnu m be rs and re fle c
t aprobable s e riou s m ism anage m e nt ofthis popu lation.
Recommendations:
1. A s m e ntione d in othe r s e c
tions ofthis re port, the foc
u s ofthe d e ntalprogram at the N R C
s hou ld re fle c
t the m iss ion ofthe ins titu tion. A lm os t allre s ou rc
e s s hou ld be d ire c
te d toward
s e e ing u rge nt c
are c
om plaints from the u nd e s ignate d , s hort term popu lation and in
provid ing the s c
re e ning e xam inations . E ve ry e ffort s hou ld be m ad e to s e e inm ate s
c
om plainingofpain or s we llingin atim e ly m anne r, within 24-48 hou rs . T he s e inm ate s
ne e d not be s c
he d u le d for ope rative d e ntistry. O nly palliative c
are ne e d be provide d . A
s ic
k-c
alls ys te m s hou ld be e s tablishe d that c
an ac
c
om plishthis goal. A d m inistration s hou ld
be involve d in this proje c
t and in as s istingthe d e ntalprogram in ge ttinginm ate s
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on C enter
P age 31
to the c
linicfor the ir appointm e nt. T he inm ate hand book s hou ld m ake it c
le ar who is
e ligible forrou tine c
are .

N o s ys te m is in plac
e to ide ntify m e d ic
ally c
om prom ise d patients and re d flagthos e that m ay ne e d
m e d ic
alc
ons u ltation priorto d e ntalproc
e d u re s . The he althhistory re view and d oc
u m e ntation is
ve ry c
u rs ory from the N R C s c
re e ninge xam ination.
Inm ate [redacted] was on C ou m ad in the rapy and had tooth#19e xtrac
te d . N o m e ntion was m ad e
in the d e ntalre c
ord and no pre c
au tions we re ad d re s s e d ord oc
u m e nte d priorto the e xtrac
tion.
Inm ate [redacted] was on P lavix anti-c
oagu lant the rapy and this was not ad d re s s e d in the d e ntal
re c
ord prior to ad e ntal e xtrac
tion on 5/13/14. W he n as ke d , D r. B rown s ays it was m anage d
properly, bu t not d oc
ord .
W he n as ke d , D r. B rown ind ic
ate d that s he d oe s not rou tine ly take blood pre s s u re s on patients with
ahistory ofhype rte ns ion.
Recommendations:
alhistory s e c
al
c
ialpre c
atc
ofthe provide r.
2. T hat blood pre s s u re re ad ings be rou tine ly take n ofpatients withahistory ofhype rte ns ion,
e s pe c
alproc
e d u re.
3. T hat the he alth history be ad d re s s e d and u pd ate d on e ve ry patient and that c
ons u ltation
withm e d ic
albe provide d and d oc
u m e nte d whe n ind ic
ate d . T his iss u e is s e riou s and ne e d s
to be c
orre c
te d im m e d iate ly.
Specialists
D r. Fre d e ric
k C raig, orals u rge on, is u tilize d by the N R C fororals u rge ry s e rvic
e s . T he inm ate s
are s c
he d u le d and m anage d from the State ville C C pare nt ins titu tion. B oth ins titu tions als o u s e
Joliet O ralSu rge ons form ore c
om plic
ate d ge ne ralane s the s iac
as e s and forfac
ialfrac
tu re s . N one
ofthe inform ation was m aintaine d at the N R C
Recommendations: N one .
Dental CQI
T he d e ntal program c
ontribu te s m onthly d e ntal s tatistic
s to the C Q I c
om m itte e . T he N R C
partic
ipate s withthe State ville C C , C Q I c
om m itte e m e e tings, as part ofthe e ntire d e ntalprogram .
T he s e m inu te s are m aintaine d at State ville C C . N o s tu d ies we re in plac
e forthe N R C at the tim e
ofthis visit. In light ofthe nu m be rofprogram we akne s s e s , this is u nac
c
e ptable .
Recommendations:
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on C enter
P age 32
1. T he C ontinu ingQ u ality Im prove m e nt proc

e s s s hou ld be u s e d e xte ns ive ly and c
ontinu ou s ly
to as s ist in c
orre c
tingthe d e ficienc
ies note d in the bod y ofthis re port. A good s tartingpoint
wou ld be to foc
u s on ad d re s s ingu rge nt c
are ne e d s in atim e ly and e fficient m anne r.

From ou r re view of m inu te s and d isc
u s s ion with the D ire c
tor ofN u rs ing, the H e althC are U nit
A d m inistrator has not be e n ove rs e e ingthis program . W e we re s hown m inu te s , bu t the m inu te s
only c
ontaine d s tu d ies pe rform e d at State ville . A s we have s aid e arlier, withou t s trongle ad e rs hip
ins u ringthat the infras tru c
tu re is in plac
e , m e aningthat logs are c
ons c
ientiou s ly m aintaine d and
the re fore u tilize d in ord e rto d o m onitoring, the qu ality im prove m e nt program has no pos s ibility
ofbe inge ffe c
tive . Su c
hlogs inc
lu d e are c
e ption proc
e s s inglog, as ic
kc
alllog, an u rge nt c
are log,
an e m e rge nc
y s e nd ou t logand as c
he d u le d offs ite visit log. W ithou t the s e s tru c
tu rale le m e nts ,
s e lf-m onitoringis e xtre m e ly d iffic
u lt, if not im pos s ible . In ou r view, the qu ality im prove m e nt
program at N R C is not fu nc
tionaland re qu ire s ac
om ple te ove rhau l.
Janu ary 2014
N orthern Rec epti

on C enter
P age 33
Recommendations
1. N R C warrants ale ad e rs hipte am c
om parable to any othe rbu s y prison, inc
lu d ingaM e d ic
al
D ire c
tor, aH e althC are A d m inistratorand aD ire c
torofN u rs ing.
2. N R C ne e d s its own s taffinggrid withs u ffic
ient staffd e d ic
ate d to m e e tingthe s e rvic
e ne e d s
ofN R C .
1. T he re s hou ld be ad e s ignate d e xam room in e ac
hhou s ingu nit appropriate ly e qu ippe d for
c
ond u c
tings ic
kc
all.
Reception Processing:
1. T he policy approac
h to N R C is inc
ons iste nt with the re ality of s e rvic
e d e m and s . T he
as s u m ption that patients have the ir m e d ic
alintake c
om ple te d within awe e k and the n are
trans fe rre d ou t is not applic
able to a s u bs tantial nu m be r of patients . T he re fore , this
philos ophy m u s t be c
hange d . T his is e s pe c
ially tru e for patients withc
hronicd ise as e s or
who ne e d s c
es.
2. T he intake as s e s s m e nt by an ad vanc
e d le ve lc
linic
ian m u s t inc
lu d e qu e s tions re gard ing
c
u rre nt s ym ptom s and inc
lu d e the d e ve lopm e nt ofaproble m list and re le vant plan.
3. Su ffic
ient re s ou rc
e s s hou ld be available s u c
h that the phys ic
ale xam s c
an be c
om ple te d
within one we e k ofarrival.
4. N R C m u s t be gin c
ons c
ientiou s ly u s inglogbooks, e ithe r pape r or e le c
tronic
, for intake
proc
e s s ing.
1. T he intras ys te m trans fe rproc
e s s m u s t be d e s igne d to ins u re c
ontinu ity ofc
are foride ntified
proble m s .
Medical Records:
1. T he m e d ic
alre c
ord s ofpatients at N R C who re m ain be yond two we e ks orwho are hou s e d
at the m inim u m -s e c
u rity u nit m u s t be m anage d in e xac
tly the s am e m anne ras patients at
any pe rm ane nt ins titu tion.
2. M e d ic
alre c
ord s s taffingm u s t be ad e qu ate to ins u re that re c
ord s ofpatients who s tay m ore
than two we e ks orwho are hou s e d in M SU are m aintaine d in the s am e m anne rpe rD O C
polic
y as re c
ord s at pe rm ane nt ins titu tions .
Sick call:
1. O ffic
e rs m u s t be e lim inate d from the proc
e d u re s that e nable inm ate s to re qu e st he althc
are
s e rvic
e s ;thu s , inm ate s m u s t e ithe rplac
e the re qu e s ts in aloc
kbox orgive the m to he alth
c
are s taff.
2. T he re m u s t be ongoingprofe s s ional pe rform anc
e re view of both nu rs e s ic
k c
all and
ad vanc
e d le ve lc
linic
ian s ic
kc
all, whic
hinc
lu d e s fe e d bac
k on ind ivid u alc
as e s in ord e rto
im prove profe s s ionalpe rform anc
e.
ons c
ientiou s ly u s inglogbooks , eithe rpape rore le c
tronic
, fors ic
kc
all.
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on C enter
P age 34
Chronic Disease:
1. T he polic
y re gard ingc
hronicd ise as e s m u s t be that patients who re m ain be yond two we e ks
m u s t have the irinitialc
hronicc
are visit at N R C be fore atotalof30d ays have pas s e d . T his
is c
le arly the c
as e rou tine ly withhighe rs e c
u rity inm ate s .
ons c
ientiou s ly u s inglogbooks , eithe rpape rore le c
tronic
, forthe c
hronic
d ise as e program .
Medication Administration:
1. M e d ic
ation ad m inistration m u s t inc
lu d e ad e s ignate d offic
e rto e s c
ort the nu rs e and ins u re
that patients appropriate ly id e ntify the m s e lve s withthe irID c
ard , that the y bringwate rin
ac
ontaine r s o as to inge s t the m e d ic
ation, and s o that the offic
erc
an d o am ou thc
he c
k
afte ringe s tion.
Urgent/Emergent Care:
ons c
ientiou s ly u s ing logbooks , e ithe r pape r or e le c
tronic
, for
u rge nt/e m e rge nt c
are .
Scheduled Offsite Services-Consultations/Procedures:
1. P atients whos e proble m s re qu ire s c
e s who are a highe r le ve l of
sec
u rity m u s t have thos e s c
he d u le d while at N R C .
ons c
ientiou s ly u s inglogbooks , e ithe rpape rore le c
tronic
, fors c
he d u le d
offs ite s e rvic
es.
1. T he qu ality im prove m e nt program m u s t be re e ne rgize d withknowle d ge able le ad e rs hipthat
has be e n provide d s pe c
ifictraining re gard ing qu ality im prove m e nt philos ophy and
m e thod ology.
c
olle c
tion.
s trate gies .
Janu ary 2014
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on C enter
P age 35

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
P atient #11
P atient #12
P atient #13
P atient #14
P atient #15
P atient #16
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Provider Sick Call:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
Name
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
Janu ary 2014
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
N orthern Rec epti

on C enter
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P age 36
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Infirmary:
Patient Number
P atient #1
P atient #2
P atient #3
Janu ary 2014
Name
[redacted]
[redacted]
[redacted]
N orthern Rec epti

on C enter
Inmate ID
[redacted]
[redacted]
[redacted]
P age 37
Dixon Correctional Center

(DCC) Report
February 2014

Ron Shansky, MD
Karen Saylor, MD
Larry Hewitt, RN
Karl Meyer, DDS
Contents
Overview....................................................................................................................................3
Findings .....................................................................................................................................4
C linicSpac
e and Sanitation .....................................................................................................7
Intras ys te m T rans fe r................................................................................................................7
M e d ic
alR e c
ord s ......................................................................................................................9
N u rs ingSic
k C all.....................................................................................................................9
C linic
ian Sic
k C all.................................................................................................................13
P harm ac
y/M e d ic
ation A d m inistration....................................................................................21
Laboratory .............................................................................................................................21
U ns c
he d u le d Se rvic
e s /E m e rge nc
y Se rvic
e s ...........................................................................22
Sc
e s ....................................................................................................23
Infirm ary C are .......................................................................................................................25
Infe c
tion C ontrol...................................................................................................................32
D e ntalP rogram ......................................................................................................................32
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 2
Overview
O n Fe bru ary 26-28, 2014we visite d the D ixon C orre c
tionalC e nte r(D C C )in D ixon, Illinois. T his
was ou rfirs t s ite visit to D C C and this re port d e s c
ribe s ou rfind ings and re c
om m e nd ations . D u ring
this visit, we :
al
als e rvic
e s are a
are s taff
u m e nts
W e thank W ard e n C hand le r and he r s tafffor the ir as s istanc

e and c
ooperation in c
ond u c
tingthe
re view.
Executive Summary
D ixon is am u lti-m iss ion prison that hou s e s m ale offe nd e rs withs pe c
ialne e d s inc
lu d ings e riou s ly
m e ntally ill, d e ve lopm e ntally d isable d and ge riatricinm ate s with c
ognitive and /or m obility
im pairm e nts , and ahos pic
e program . T he c
u rre nt popu lation is 2349 inm ate s . T he ins titu tion is
not are c
e ption c
e nte rbu t has a28-be d infirm ary and m e ntalhe althm iss ion. A pproxim ate ly 70%
orm ore are on m e d ic
ations .
T he vac
u u m of le ad e rs hip from the M e d ic
alD ire c
tor pos ition, the D ire c
torofN u rs ingpos ition
and the H e althC are U nit A d m inistratorpos ition have re s u lte d in bre akd owns withalm os t e ve ry
m ajor s e rvic
e that inm ate s re c
e ive . T he non-c
om plianc
e with D O C polic
ies is at le as t in part
attribu table to the s e vac
anc
ies bu t als o pos s ibly to line s taffpos ition vac
anc
ies . T he e nd re s u lt is
liability for boththe inm ate s and the s tate . T his liability be gins withthe abs e nc
e ofafu nc
tional
intras ys te m trans fe r proc
e s s im ple m e nte d to fac
ilitate c
ontinu ity of re qu ire d s e rvic
e s . In othe r
fac
ilities , ne wly trans fe rre d patients are brou ght to the m e d ic
alare ato initiate this c
ontinu ity. T his
is not c
ons iste ntly happe ningat D ixon. In fac
t, som e inm ate s go le ngthy pe riod s oftim e be fore
this proc
e s s is initiate d . A d d itionally, u ns c
e s or u rge nt/e m e rge nt s e rvic
e s are not
logge d ortrac
ke d in any way. W e atte m pte d to re view s om e re s pons e s throu ghrand om ly provid e d
inc
id e nt re ports . T he re is no pos s ibility, the re fore , that the re c
an be an organize d proc
e s s to
d e te rm ine tim e line s s and appropriate ne s s ofre s pons e s from bothnu rs ings taffand c
linic
ian s taff.
In ad d ition, we fou nd c
as e s whe re the follow-u p was d e fic
ient bu t ofc
ou rs e the ins titu tion was
u nable to ide ntify this.
E ve n the c
linic
ian s ic
kc
allwas not trac
ke d withthe loggings ys te m and the re fore the page s we
we re provid e d that liste d patients who we re s e e n by s pe c
ificc
linic
ians we re ove rwhe lm ingly not
s e e n at allornot s e e n within awe e k ofthe d ate liste d on the page s provide d .
Sc
e s we re frau ght with le ngthy d e lays , m os t e s pe c
ially afte r the W e xford
phys ic
ian had give n ve rbalapprovalofthe s e rvic
e . T he U ofI c
oord inatorsom e tim e s d id not
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 3
he ar ofthe offic
ialau thorization withanu m be r for u pto two m onths afte r the ve rbalapproval.
T he e nd re s u lt is s ignific
ant d e lays in ac
c
e s s to s e rvic
e s . M any s e rvic
e s , onc
e the au thorization
nu m be ris provide d , d o not oc
c
u rforas m u c
has thre e to five m onths . T he re is no re gu larfollowu p ofthe s e patients in the inte rim and s om e tim e s e ve n afte r the s e rvic
e is provide d the re is not
appropriate follow-u pto ins u re c
ontinu ity ofc
are .
T he re is no s ingle d e s ignate d c
hronicc
are nu rs e . R athe r, e ac
hnu rs e is as s igne d as ingle c
hronic
d ise as e c
linic
. T he re s u lt is afragm e nte d and d isjointe d program withno c
ohe s ive ove rs ight. It
was not s u rprising, the re fore , that we fou nd that the program is not be ingu tilize d e ffe c
tive ly;we
c
am e ac
ros s m any patients withc
hronicillne s s e s who we re not e nrolle d in the program and othe rs
who we re e nrolle d bu t not s e e n ac
c
ord ingto polic
y.
M e d ic
alre c
ord s are not ad e qu ate ly m aintaine d . M any are ove rs tu ffe d withou td ate d inform ation
while lac
kingc
u rre nt re ports and M A R s . P roble m lists are ofte n not ke pt u pd ate d .
T he infirm ary had m u ltiple d e fic
ienc
ies . LP N s are workingou ts ide the s c
ope of prac
tic
e , and
patients are not s e e n ac
c
ord ingto polic
y by provid e rs . R are ly is the re e vid e nc
e that patients are
phys ic
ally e xam ine d by the provide r. D oc
u m e ntation was ins u ffic
ient in te rm s ofd ate s /tim e s , vital
s igns , s ignatu re s and the re qu ire d SO A P form at was not always u s e d . C allbu ttons we re pos itione d
whe re it c
ou ld be d iffic
u lt orim pos s ible forthe patient to ac
c
e s s ;the re we re no c
allbu ttons in the
patient room s alongone longhallway and no d ire c
t line -of-s ight to the nu rs ings tation in s ix ofthe
room s . T he re was no s e c
u rity pre s e nc
e in the infirm ary d e s pite the pre s e nc
e of inm ate s of all
sec
u rity c
las s ific
ations . T he re was ins u ffic
ient e qu ipm e nt and s u pplies .
H avingd e s c
ribe d the above d e fic
ienc
ies , it is not su rprisingthat the qu ality im prove m e nt program
is non-fu nc
tional. A lthou ghthe re are m e e tingm inu te s from A u gu s t 2013and D e c
e m be r2013, in
ne ithe rofthos e m e e tings was the re any d isc
u s s ion ofhow to im prove the qu ality ofs e rvic
e s . T he
pe rs on as s igne d to ru n the program has had no trainingand ad m its that s he is not knowle d ge able
abou t how to perform this d u ty. A s allu d e d to e arlier, in this fac
ility the re we re alm os t no fu nc
tional
logbooks u s e d to trac
k and the re fore c
apable of be ing u tilize d for s e lf-m onitoring and
im prove m e nt ac
tivities . T he re fore , it is not s u rprising that virtu ally no s e lf-m onitoring and
c
e rtainly no im prove m e nt ac
tivities are oc
c
u rring.
Findings
A t the tim e of ou r visit, the H e alth C are U nit A d m inistrator pos ition was vac
ant as we llas the
D ire c
torofN u rs ingpos ition. B othpos itions are s tate pos itions . A d d itionally, the re was an ac
ting
M e d ic
alD ire c
tor, whic
his aW e xford pos ition, be c
au s e that pos ition had be e n vac
ant s inc
e A u gu s t.
T he W e xford phys ic
ian fillingin forthe M e d ic
alD ire c
tor, whe n qu e ried abou t the M e d ic
alD ire c
tor
d u ties s he pe rform e d , d e s c
ribe d prim arily be ingre s pons ible for the s c
es
u tilization m anage m e nt and be ingavailable to c
ons u lt withnu rs e s and othe rc
linic
ians whe n s he
was ons ite . She was not on c
all, s he provide d no training for staff and s he he rs e lf was not
knowle d ge able withre gard to the qu ality im prove m e nt program . She d id no c
linic
alpe rform anc
e
as s e s s m e nts . A t afac
ility withas c
om ple x am e d ic
alm iss ion as the D ixon
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 4
C orre c
tionalC e nte r, the le ad e rs hipvac
u u m raise d are d flag, whic
hwas u ltim ate ly s u pporte d by
ou r c
linic
al find ings. T he s e vac
anc
ies m u s t be fille d as qu ic
kly as pos s ible . T he re we re two
s u pe rvisory nu rs ingpos itions , one as tate nu rs e and one aW e xford nu rs e .
table :Table 1. Health Care Staffin
Position
M e d ic
alD ire c
tor
StaffP hys ic
ian
N u rs e P rac
titione r
D ire c
torofN u rs ing
C orre c
tions N u rs e I
C orre c
tions N u rs e II
Lic
e ns e d P rac
tic
alN u rs e s
.
P hle botom ist
R ad iology T e c
hnic
ian
P harm ac
y Tec
hnic
ian
P harm ac
y Tec
hnic
ian
StaffA s s istant I
C hiefD e ntist
D e ntist
O ptom e try
P hys ic
alT he rapist
P hys ic
Total
Current FTE
1.0
1.0
2.0
1.0
1.0
1.0
1.0
16.0
2.0
8.0
10.0
6.0
1.0
1.0
0.5
1.0
3.0
1.0
1.0
3.0
1.0
0.4
1.0
1.0
0.2
0.2
1.0
66.3
Filled
0
1.0
1.0
0
0
1.0
1.0
9.0
2.0
7.0
9.0
4.0
0
1.0
1.0
1.0
3.0
1.0
0
3.0
1.0
0.4
1.0
1.0
0.2
0.2
0
48.8
Vacant State/Cont.
1
C ontrac
t
0
C ontrac
t
1
C ontrac
t
1
State
1
State
0
State
0
C ontrac
t
7
State
0
State
1
C ontrac
t
1
C ontrac
t
2
C ontrac
t
1
State
0
State
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
State
1
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
State
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
1
C ontrac
t
18 (10
state & 8
contract)
Staffing Concerns
O fpartic
u larc
onc
e rn are the vac
ant M e d ic
alD ire c
tor, H e althC are U nit A d m inistratorand D ire c
tor
ofN u rs ingpos itions and the le ngthoftim e the y have be e n vac
ant. T he s e thre e pos itions repre s e nt
the le ad e rs hipte am ofthe m e d ic
ald e partm e nt. To have one ofthe thre e pos itions vac
ant re pre s e nts
as ignific
ant ne gative im pac
t on the m e d ic
alprogram , bu t to have allthre e
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 5
vac
ant s pe lls d isas te r. E ve n thou gh ad m inistrative s taff has be e n as s igne d to ove rs e e the
d e partm e nt and has worke d hard to hold the program togethe r, this s trate gy is like plac
ingas m all
band -aid on ve ry large wou nd .
W hile the re are two s u pe rvisingR N s , bothare ne w to the irpos itions , and one R N is e m ploye d by
the s tate and the othe ris e m ploye d by the m e d ic
alve nd orand fu nc
tions prim arily as the ve nd or
s
s ite c
ontrac
t m anage r. A s a re s u lt, the ir m iss ions are not c
om ple te ly aligne d . E ac
h of the
ind ivid u als ne e d s to be m e ntore d , to be tau ght, to be m onitore d and to be e valu ate d . T his c
an only
be ac
c
om plishe d by he alth c
are e d u c
ate d , c
re d e ntiale d and lic
e ns e d m e d ic
al d e partm e nt
ad m inistrative s taff, i.e ., aD ire c
torofN u rs ingand H e althC are U nit A d m inistrator.
N u rs ings c
he d u lingis in s ham ble s as are s u lt ofe ac
hs u pe rvisingnu rs e s c
he d u linghe rown s taff,
i.e ., s tate e m ploye d or ve nd or e m ploye d . A s a re s u lt, c
ou ple d with s ignific
ant s tate nu rs ing
vac
anc
ies , ove rtim e is u s e d d aily to provid e for m inim u m s taffing. M inim u m s taffingre s u lts in
m inim u m ac
c
om plishm e nt as the re is not e nou ghs taffto e ffe c
tive ly c
om ple te re qu ire d tas ks s u ch
as c
om ple te c
harting, intake inte rviews , phys ic
ale xam inations , c
hronicillne s s c
linic
s , E K Gs and
s ic
kc
all. T he D ire c
torofN u rs ingpos ition provid e s fors pe c
ificove rs ight ofthe nu rs ingfu nc
tion
throu ghc
e ntralize d s c
he d u ling, training, m onitoringand e valu atingnu rs ings taffpe rform anc
e.
T he H e althC are U nit A d m inistratorpos ition provid e s am e d ic
alad m inistrative pe rs pe c
tive ofthe
totalm e d ic
alprogram and m iss ion. T he pos ition re qu ire m e nts go be yond ju s t s u pe rvision ofs taff
bu t, m ore im portantly, the c
ons tant m onitoring, e valu atingand e d itingofthe program to as s u re
c
om plianc
e withe s tablishe d polic
y and proc
e d u re and the e nhanc
e m e nt ofbothm e d ic
als e rvic
es
d e live ry and the qu ality ofs e rvic
e s . T his is not aone tim e e ffort, as c
ons tant m onitoring, e valu ating
and e d itingare re qu ire d .
W hile on pape rthe M e d ic
alD ire c
torhou rs are be ingfille d by am e d ic
alve nd orprovid e d trave lling
phys ic
ian, it c
annot be argu e d this arrange m e nt is the e qu ivale nt of havingafu ll-tim e M e d ic
al
D ire c
tor. W ith this arrange m e nt, the re is no owne rs hip of the program , no c
ontinu ity of
ad m inistrative ove rs ight and no c
ontinu ity ofm e d ic
alau thority as re qu ire d by the c
om pre he ns ive
he althc
are c
ontrac
t.
ID O C polic
y re qu ire s pe riod icage and ge nd e rs pe c
ificphys ic
ale xam inations are c
ond u c
te d and
d oc
u m e nte d d u ringthe inm ate
s birthm onth. O f10re c
ord s re viewe d , five we re proble m atic
, with
m u ltiple d e fic
ienc
ies . T he proble m s note d we re :
1.
2.
3.
4.
N
N
N
N
o d oc
u m e nte d e ye e xam ination in two re c
ord s
o d ate and tim e ofe xam ination note d ors ignatu re ofthe nu rs e
o d oc
u m e nte d nu rs ingas s e s s m e nt in two re c
ord s
o d oc
u m e nte d phys ic
ian tre atm e nt plan in one re c
ord
T his c
onfirm s the re m ay be proble m s withbothad m inistrative s u pe rvision and s taffing.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 6

D ixon C orre c
tionalC e nte r originally ope ne d in 1918 for the c
are of e pile ptic
s bu t soon hou s e d
m e ntally illpatients . T he D e partm e nt ofM e ntalH e althas s u m e d c
ontrolin 1961and c
hange d the
nam e to the D ixon D e ve lopm e ntalC e nte r in 1975. T he d e ve lopm e ntalc
e nte r was later c
los e d ,
pu rc
has e d by the Illinois D e partm e nt ofC orre c
tions and re ope ne d in 1983 as am e d iu m s e c
u rity
ad u lt m ale fac
ility hou s ingalarge m e ntalhe alth, s pe c
ialne e d s and ge riatricpopu lations .
A s are s u lt ofthe originalm e ntalhe althhos pitald e s ign, the c
u rre nt m e d ic
albu ild ingis alarge
thre e -s tory bu ild ings e rvingm u ltiple fu nc
tions . A llthre e floors are he ate d and air-c
ond itione d .
T he firs t floor inc
lu d e s alarge inm ate waitingare a, x-ray s u ite , d e ntalc
linic
, optom e try c
linic
,
m e d ic
ation pre paration and s torage , m e d ic
alre c
ord s , proc
e d u re room , library, two nu rs e s ic
kc
all
e xam ination room s , thre e phys ic
ian/N P e xam ination room s and m u ltiple offic
es.
T he s e c
ond floor, ac
c
e s s e d by e le vatororstairs , is d ivid e d in halfwitha25-be d m obility im paire d
u nit (A D A )and the othe rhalfbe inga28-be d infirm ary. A t the tim e ofthe ins pe c
tion, the re we re
19patients in the A D A u nit, and 22patients in the infirm ary.
T he third floor, als o ac
c
e s s ible by e le vatorors tairs , is an 84-be d ge riatricu nit. T o be e ligible , a
patient m u s t be at le as t age 50and have two orm ore d iagnos e d c
hronicillne s s e s . A t the tim e of
the ins pe c
tion, all84be d s we re fu ll.
T he bu ild ingwas re as onably cle an, we lllighte d and we llm aintaine d . T he re are inm ate porte rs
as s igne d to e ac
hfloorforc
le aningpu rpos e s . Ind ivid u als hou s e d on the third floorare re s pons ible
to ke e pthe irroom s c
le an, and inm ate porte rs provid e the janitorials e rvic
e s forthe c
om m on are as .
M e d ic
al are as are obs e rvingblood -borne pathoge n pre c
au tions , and a lic
e ns e d m e d ic
al was te
d ispos alc
om pany is u s e d .
T he be d s on the third floorappe are d e xtre m e ly old and worn. O fs ignific
ant c
onc
e rn was the s tyle
ofbe d be ingu s e d , whic
hwas as te e lfram e withas ys te m ofinte rc
onne c
te d s prings on whic
hthe
m attre s s is laid . T he s tyle is proble m aticforthe s e re as ons :
1. T he re are s ignific
ant s e c
u rity c
onc
e rns s inc
e m any parts of the be d c
an be e as ily take n
apart and fabric
ate d into awe apon.
2. T his s tyle of s prings u pport s ys te m is proble m aticfor old e r patients d u e to it c
au s ing
c
hronicbac
k pain, s tiffne s s and los s offle xibility and m obility.
3. T he be d is d iffic
u lt to thorou ghly c
le an and s anitize be twe e n patients .
A n ad e qu ate intras ys te m trans fe rprogram be gins withpatients be ingpre s e nte d to the m e d ic
alu nit
at the tim e ofarrivalwiththe ir re c
ord s and the healthtrans fe r s u m m ary form . A nu rs e s hou ld be
re viewingthe form , ide ntifyingproble m s , m e d ic
ations , alle rgies and any appointm e nts that ne e d to
be s c
he d u le d bas e d on what is d oc
u m e nte d in the m e d ic
alre c
ord . T his s hou ld be
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 7
ac
c
om plishe d on the s am e d ay the patients arrive , bu t c
e rtainly no late r than the followingd ay
s hift. T he c
u rre nt s ys te m ind ic
ate s that the nu rs e s are not fam iliarwiththe re qu ire m e nts and are
not appropriate ly traine d ;in ad d ition, the proc
e s s is not only not m onitore d bu t nu rs ings taffare
not be ingprovide d with fe e d bac
k s o that the ir pe rform anc
e im prove s . Give n the abs e nc
e of
loggingand trac
kingby the m e d ic
alprogram , it is not at alls u rprisingthat the s e d e fic
its e xist and
u ltim ate ly, liability is c
re ate d both for the inm ate s and for the s tate. It is pos s ible that nu rs ing
pos ition d e fic
its c
ontribu te to this proble m .
W e looke d at 12re c
ord s ofpatients who e nte re d as re c
e ntly as Fe bru ary 2014and as farbac
k as
D ec
e m be rof2013. O fthe 12re c
ord s we re viewe d , the re we re proble m s withvirtu ally allofthe m .
In fac
t, we le arne d that it is u nu s u alfor the norm alintras ys te m trans fe r polic
y to be followe d .
W he n patients are brou ght in, the y are not brou ght to the m e d ic
alare a;ins te ad , anu rs e s e e s the m
and atte m pts to le arn ifthe re are any c
ritic
alm e d ic
ation ne e d s . T he re is an e ffort to re s pond to
thos e ne e d s , bu t that is the only thingthat happe ns withre gard to intras ys te m trans fe rs . W e le arne d
that d u e to staffings hortage s , the y are u nable to ac
qu it this c
ritic
alobligation. W e fou nd five
re c
ord s whic
hwe re d e laye d s ignific
antly and s e ve n whe re the y we re e ithe rnot d one at allord one
inc
orre c
tly. W e willprovide s om e e xam ple s .
Patient #1
T his is a36-ye ar-old who arrive d at D ixon on 2/4/14withm e ntalhe althproble m s and no c
hronic
m e d ic
alproble m s . H is he althtrans fe rs u m m ary has s tillnot be e n c
om ple te d .
Patient #2
T his is apatient from P inc
kne yville withm e ntalhe althproble m s and this was d one inc
orre c
tly.
T he toppart ofthe intras ys te m trans fe rorhe althtrans fe rs u m m ary is to be fille d ou t by the s e nd ing
ins titu tion bas e d on are c
ord re view. T he bottom halfis to be fille d ou t at the re c
e ivingins titu tion
and inc
lu d e s afac
e -to-fac
e d isc
u s s ion withthe inm ate ofthe s u m m arize d proble m s , m e d ic
ations ,
appointm e nts , e tc
. T he nu rs e at D ixon pu lle d ane w he althtrans fe rs u m m ary form and again fille d
ou t the top, whic
hd id not e nable vitals igns to be pe rform e d be c
au s e the nu rs e d id not e ve n s e e
the patient.
Patient #3
A lthou ghthis patient arrive d on 2/4/14, his m e d ic
alre c
ord has not arrive d . T his is anothe rc
as e in
whic
hat Shawne e the tophalfofthe form was c
om ple te d and the D ixon s taffpe rs on pu lle d anothe r
ne w form and re pe ate d that inform ation withou t talkingto the patient orpe rform ingany vitals igns .
Patient #4
T his is a37-ye ar-old as thm aticwithps yc
hproble m s . T his patient arrive d on 2/4/14, the he alth
trans fe r s u m m ary was c
om ple te d on 2/13, e ight d ays late r, bu t it lac
ke d are fe rralto the as thm a
c
linic
.
Patient #5
T his is a27-ye ar-old withm u ltiple s c
le ros is. T he he althtrans fe rs u m m ary was d one on 2/26/14,
approxim ate ly thre e we e ks afte rhe arrive d , bu t the re is no re fe rralto the c
hronicc
are c
linicforhis
m u ltiple s c
le ros is.
Patient #6
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 9
8
T his is a30-ye ar-old who arrive d 1/29/14, withm e ntalhe althiss u e s and hypothyroid ism , along
withhype rtriglyc
e ride m ia. T he trans fe rs u m m ary was c
om ple te d on 2/9, alittle m ore than awe e k
afte rhis arrival, bu t the re is no re fe rralto the c
hronicc
are program forhis hypothyroid ism and his
hype rtriglyc
e ride m ia.
Medical Records
M any he althre c
ord s we re ove rs tu ffe d and in d ire ne e d ofthinning. T his not only ham pe re d ou r
re view bu t als o m ore im portantly is an obs tac
le to the e ffic
ient d e live ry of c
are by the ons ite
provide rs . N ot only d o the c
harts ofte n c
ontain e xc
e s s ive am ou nts ofou td ate d inform ation, bu t
als o c
u rre nt re ports and M A R s are ofte n m iss ing. A s d e s c
ribe d in the C hronicD ise as e s e c
tion of
this re port, we fou nd pile s ofM A R s d atingbac
k for m onths in the m e d ic
alre c
ord s d e partm e nt.
T his of c
ou rs e re nd e rs it ne arly im pos s ible for provide rs to obje c
tive ly m onitor patients
m e d ic
ation c
om plianc
e.
T he infirm ary c
harts are e s s e ntially s m allpile s ofloos e filingc
lippe d into anc
ient m e talc
lipboard s .
T he pe rm ane nt file s are als o ke pt in the infirm ary, bu t the s e are not u s e d forc
hartinge ve n whe n
patients are pe rm ane ntly hou s e d in the infirm ary. Las tly, we note d that proble m lists we re ofte n
not ke pt u pto d ate .
Nursing Sick Call

N u rs ings ic
kc
allis c
ond u c
te d d aily, M ond ay throu ghFrid ay.
N u rs ings ic
kc
all, at this tim e , is d iffic
u lt to as s e s s d u e to the followingfou rre as ons :
1.
2.
3.
4.
T he fac
ility is u s ingtwo d iffe re nt proc
e d u re s forinm ate s to ac
c
e s s s ic
kc
all.
W he n s ic
kc
allre qu e s t s lips are u s e d , the y are not be ingtriage d by an R N .
T he re is no m ainte nanc
e ofs ic
kc
allre qu e s t s lips oras ic
kc
alllog.
N on-R N s are c
ond u c
tings ic
kc
all.
T he firs t proc
e d u re be ingu se d fors ic
kc
allis the s ic
kc
allrequ e st s lipm e thod . C u rre ntly, an inm ate
c
om ple te s arequ e st s lip and give s it to ac
orre c
tionaloffic
e r, who plac
e s the requ e st in aloc
ked
ins titu tionalge neralm aild rop box loc
ated in the hou s ingarea. Institu tionalm ails taffc
olle c
ts all
m ail, inc
lu d ingthe s ic
k c
all requ e st s lips , from e ac
h d rop box d aily and c
arries the m to the
ins titu tionalm ailroom , whe re allpiec
e s ofm ailare sorte d and d e live re d to e ac
hd e partm e nt. O nc
e
d e live re d to the m e d ic
ald e partm e nt, the s lips are forward e d to nu rs ing, and anu rs ings taffm e m be r,
whic
hc
ou ld be an R N su pervisor, staff R N or LP N , re views e ac
h requ e st s lip and write s the
ind ividu al
s nam e , nu m be r, c
om plaint and d ate to be e valu ated on as ic
kc
alls c
he d u le . A t this point
in the proc
e s s, the originals ic
kc
allre qu e st s lip is thrown away. E ither the inm ate is e s c
orte d or
re ports to the m e d ic
ald e partm e nt fors ic
kc
allbas e d on the d ate the nu rs ings taffm e m be rre c
ord s
on the s ic
kc
alls c
he d u le . W iththis m e thod , m e d ic
als taffretains the m ost c
ontroloverthe s ic
kc
all
sc
he d u le , s inc
e the y are d oingthe sc
he d u ling. B y ID O C polic
y, onc
e
re c
e ive d , re qu e s t s lips are to be triage d within 24 hou rs and c
ate gorize d as to u rge nt or rou tine ,
withind ivid u als in the u rge nt c
ate gory be inge valu ate d the s am e d ay orno late rthan the ne xt, and
ind ivid u als in the rou tine c
ate gory be inge valu ate d within 72hou rs .
Sinc
e the originalre qu e s t is be ingd e s troye d , the re is no way to d ete rm ine if the re qu e s t was
initially triage d , c
ate gorize d and the inm ate e valu ate d within the appropriate tim e fram e . Sim ilarly,
s inc
e as ic
kc
alllogis not m aintaine d , the re is no way to m e as u re c
om plianc
e withthe s e s am e
polic
y re qu ire m e nts .
A d d itionally, withthis proc
e s s the re are m any m e d ic
alc
onfid e ntiality bre ac
he s . Firs t, the inm ate
is re qu ire d to give his c
om ple te d re qu e s t s lipto non-m e d ic
alpe rs onne l. T he s lipis the n plac
e d in
age ne ral m ail d rop box. A s are s u lt, m ore non-m e d ic
al pe rs onne l are c
olle c
tingall the m ail,
inc
lu d ingthe s ic
kc
allre qu e s t s lips . A llthe m ailis the n trans porte d to the ins titu tionalm ailroom
fors orting, whe re m ore non-m e d ic
alpe rs onne lare hand lingc
onfid e ntials ic
kc
allre qu e s ts . Finally,
the m ailis d e live re d to e ac
hd e partm e nt by non-m e d ic
alpe rs onne l.
Sic
kc
allproc
e d u re nu m be r2be ingu s e d is an arm y-type s ic
kc
allproc
e s s . Inm ate s are inform e d
that ifthe y s ign-u pfors ic
kc
allpriorto 4p.m ., the y willbe e valu ate d the ne xt d ay. W iththis type
of s ic
kc
allproc
e s s , the m e d ic
ald e partm e nt has no c
ontrolove r s c
he d u ling. D e pe nd ingon the
nu m be rofinm ate s who s ign-u p, the m e d ic
ald e partm e nt c
ou ld have to e valu ate one or100inm ate s
withno re gard fors taffingre qu ire m e nts orothe rrequ ire d he althc
are ac
tivities . A d d itionally, while
the re are no bre ac
he s ofm e d ic
alc
onfid e ntiality withthis type ofproc
e s s , this m e thod take s away
from any as s e s s m e nt as to whe the rthe ind ivid u al
sc
om plaint is ofan u rge nt orrou tine natu re , and
ind ivid u als withbe nign re qu e s ts c
ou ld be e valu ate d priorto ind ivid u als withm ore u rge nt iss u e s .
Las tly, the are as be ingu s e d in the m e d ic
al d e partm e nt to c
ond u c
t s ic
kc
all are u nac
c
e ptable
be c
au s e :
1. T he y are poorly e qu ippe d .
2. T he re are no e xam table s on whic
hto c
ond u c
t aprope re xam ination.
3. A t tim e s , ahallway is u s e d whe re again the re are no e xam ination table s and no privacy
is available orc
onfid e ntiality m aintaine d .
O u ts id e the m e d ic
ald e partm e nt, an u nac
c
e ptable form ofs ic
kc
allis be ingc
ond u c
te d in the X H ou s e . In this hou s ingare a, nu rs ings taff, ge ne rally, Lic
e ns e d P rac
tic
alN u rs e s (LP N s )go d oorto-d oor inqu iringas to whe the r the re are any he althc
are c
om plaints . Ifthe ans we r is ye s , the
LP N talks withthe patient/inm ate throu ghthe c
e lld oor. B as e d on the c
onve rs ation, the LP N e ithe r
tre ats the patient from e s tablishe d tre atm e nt protoc
ols or re fe rs the patient to a prim ary c
are
provide r.
T his is not s ic
kc
allbu t only afac
e -to-fac
e triage . T he re is no as s e s s m e nt by qu alified m e d ic
al
s taff and no appropriate hand s -on e xam ination. A s a re s u lt, it c
annot be c
ons ide re d an
appropriate s ic
kc
allc
ontac
t, and the patient m u s t be re fe rre d to aprim ary c
are provid e r.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 10
In ord e rforthe above proc

e s s to work c
orre c
tly, the c
om plaint m u s t be triage d by an R N and , if
ne c
e s s ary, the patient/inm ate re m ove d from his c
e llto an e xam ination are awhe re the R N c
an
c
ond u c
t an appropriate e xam ination while afford ingthe patient privac
y and c
onfid e ntiality.
P e r ID O C polic
y, inm ate s are c
harge d ac
o-pay for non-e m e rge nc
y s e lf-ge ne rate d he alth c
are
re qu e s ts . In inve s tigatingthe s ic
kc
allproc
e s s , it was le arne d that bothphys ic
ian and nu rs ings taff
are lim itinginm ate s to one c
om plaint pe rs ic
kc
allc
ontac
t and only ad d re s s ingone c
om plaint pe r
c
ontac
t. T his prac
tic
e was c
onfirm e d by both staff and inm ate s . O ne c
om plaint pe r visit is
inappropriate and u nac
c
e ptable . A llofapatient
s proble m s m u s t be ad d re s s e d at an e nc
ou nte ror
aplan d e ve lope d to ad d re s s the proble m in the ne arfu tu re . A s s e s s ingonly one proble m d u ringa
s ic
kc
allvisit c
re ate s the im pre s s ion the s ic
kc
allproc
e s s has be e n d e ve lope d to ge ne rate m ore
re ve nu e .
D aily we llne s s c
he c
ks are c
ond u c
te d by nu rs ings taffon the 3p.m . to 11p.m . s hift forallinm ate s
in c
onfine m e nt or loc
k-d own s tatu s . W e e kly rou nd s are c
ond u c
te d by the nu rs e prac
titione r.
T he s e rou nd s are d oc
u m e nte d in as e gre gation logloc
ate d in the s e gre gation u nit. In the e ve nt of
ahe alth c
are c
om plaint, the nu rs ings taff m e m be r, R N or LP N , d oc
u m e nts the c
om plaint on a
m e d ic
alu nitprogre s s note whic
his file d in the s e gre gation log. A gain, the as s e s s m e nt is pe rform e d
throu ghthe d ooru nle s s the inm ate is trans porte d to the m e d ic
alu nit foram ore d etaile d as s e s s m e nt
and e xam ination. O nc
e the inm ate is re le as e d from s e gre gation, the progre s s note d etailingthe
c
om plaint is file d in the pe rm ane nt m e d ic
alre c
ord .
A gain, the re are m u ltiple iss u e s as follows :
1. T he as s e s s m e nt c
ou ld be c
ond u c
te d by non-qu alified m e d ic
als taff.
2. A c
e ll-s id e e nc
ou nte roc
c
u rs rathe rthan ale gitim ate s ic
kc
alle nc
ou nte r.
3. T he inm ate /patient is afford e d no privac
y/c
onfid e ntiality in e xpre s s inghis c
om plaint
to the nu rs e .
4. T he re is no appropriate as s e s s m e nt of the c
om plaint and c
orre s pond ingappropriate
e xam ination.
5. T he re is ahu ge bre ac
h of patient c
onfid e ntiality by filingthe progre s s note which
d e tails the m e d ic
alc
om plaint in the s e gre gation log.
T he followingm e d ic
alre c
ord s we re s e le c
te d forreview at rand om from s ic
kc
alls c
he d u le s .
Patient #1
T his patient arrive d at D ixon 12/31/2013and s igne d are fu s alto be s e e n in s ic
kc
all.
Patient #2
T his patient arrive d at D ixon 10/2/2013 and was e valu ate d by R N 11/27/2013 for c
om plaint of
right e arpain. T he e nc
ou nte rwas in SO A P form at withR N N ote he ad ing, d ate and tim e , vital
s igns , d oc
u m e nte d e are xam , no d u ration note d and tre atm e nt pe rprotoc
ol. Sic
kc
all2/6/2014by
R N . C om plaint of right foot pain for 12 hou rs . E nc
ou nte r in SO A P form at with R N N ote
he ad ing, d ate and tim e , vitals igns and ad oc
u m e nte d e xam ination ofthe foot. P atient was re fe rre d
to the M .D . and e valu ate d the s am e d ay.
Patient #3
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 11
T his patient arrive d at D ixon (no d ate ) and was e valu ate d by R N 2/4/2014 for c
om plaint of
e xc
ru c
iatingpain ofthe right hand . T he e nc
ou nte rwas in SO A P form at withR N N ote he ad ing,
d ate and tim e , no d u ration note d , no vitals igns note d , d oc
u m e nte d hand e xam ination. P atient
re fe rre d to m id -le ve lprovid e rand e valu ate d the s am e d ay. Sic
kc
all2/6 by LP N . T he e nc
ou nte r
was in SO A P form at withLP N N ote he ad ing, d ate , no tim e and no vitals igns . C om plaint ofras h
on right s ide ofne c
k, fe e t and groin are a. N o d u ration note d . D oc
u m e nte d e xam ination ofne c
k,
fe e t and groin. A s s e s s m e nt ofT ine ape d is. Tre ate d pe rtre atm e nt protoc
ols bu t pre -printe d protoc
ol
s he e t not u s e d ;give n e d u c
ation. Sic
kc
all2/21 by R N . T he e nc
ou nte rwas in SO A P form at with
R N N ote he ad ing. C om plaint ofpain in the right kne e and right wrist. D ate bu t not tim e , vital
s igns , no d u ration of pain note d . N o d oc
u m e nte d e xam ination bu t as s e s s m e nt of d e ge ne rative
arthritis whic
his not c
ove re d in nu rs ingprotoc
ols . P atient give n wrist brac
e , s oft kne e brac
e and
M otrin inc
re as e d from 400m g. B ID to 600m g. B ID bu t no d u ration note d . P atient was ins tru c
te d
to retu rn as ne e d e d .
Patient #4
T his patient arrive d at D ixon 4/9/2003 and was e valu ate d in s ic
kc
all 1/20/2014 by LP N for
c
om plaint ofd and ru ff. P re -printe d protoc
olform in SO A P form at u s e d . D ate and tim e , no vital
s igns e xc
e pt for te m pe ratu re . N o e xam ination ofs c
alp note d . Give n anti-d and ru ff s ham poo pe r
protoc
ol.
Patient #5
T his patient arrive d at D ixon 1/18/2012. R N s ic
kc
all2/25/2014 for c
om plaint he los t atooth
filling. SO A P form at, d ate and tim e , vitals igns , d u ration note d and re fe rre d to d e ntaland s e e the
s am e d ay.
Patient #6
kc
all5/15/2013forc
om plaint ofc
u ttingthe tipof
his right thu m bon his be d . SO A P form at, d ate /tim e , vitals igns , tim e ofac
c
id e nt;d oc
u m e nte d
d esc
ription of inju ry, e xam ination and as s e s s m e nt. T re atm e nt provid e d with no re fe re nc
e to a
protoc
ol. D oc
u m e nte d tre atm e nt was to was h wou nd with s oap and wate r, apply antibiotic
ointm e nt, band age ;gave T D A P and e d u c
ation. R N s ic
kc
all2/18/2014forc
om plaint ofhe artbu rn
and c
onge s te d e ars . N o SO A P form at and no note d vitals igns . D ate /tim e and e ar e xam ination
note d . H istory ofhe artbu rn note d and M ylantaworke d we llin the pas t. T he re was no re fe re nc
e
to the u s e ofaprotoc
olbu t M ylantatable ts we re give n. T he e ar c
onge s tion was not ad d re s s e d .
R N s ic
k c
all 2/25 for c
om plaint that the M ylanta table ts we re not he lping. SO A P form at,
d ate /tim e , vitals igns and history d oc
u m e nte d ;re fe rre d to M .D . bu t not ye t e valu ate d as of2/28.
Patient #7
kc
all12/24/2013as afollow-u pto right le gm u s c
le
pain on 11/25/2013. C om plainingright le gc
ontinu e s to hu rt as we llas s hou ld e r. SO A P form at,
d ate /tim e and vitals igns note d . N o notation as to whic
hs hou ld e rwas hu rtingorthe d u ration. N o
e xam ination note d . T he as s e s s m e nt was pain.P atient re fe rre d to the phys ic
ian and told it wou ld
be 10-14d ays be fore he wou ld be s e e n. P atient e valu ate d by the phys ic
ian on 1/8and 2/21/2014.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 12
Patient #8
T his patient arrive d at D ixon 12/15/2013. LP N s ic
kc
all2/25/2014forc
om plaint ofd and ru ff. T he
d and ru ff pre -printe d protoc
ol form was u s e d . T he d ate /tim e , vital s igns , d u ration and pas t
su c
c
e s s fu ltre atm e nt was note d . D oc
u m e nte d e xam ination of s c
alp whic
h re fe re nc
e d e xte ns ive
flakine s s ofs c
alp. A ntidand ru ffs ham poo provide d pe rprotoc
ol.
Patient #9
T his patient arrive d at D ixon 2/18/2010. LP N s ic
kc
allfor c
om plaint ofright s ide d pain. SO A P
form at, d ate /tim e , vitals igns and history ofan old inju ry d oc
u m e nte d . N o d oc
u m e nte d phys ic
al
e xam ination oras s e s s m e nt and re fe rre d to the phys ic
ian. N o d oc
u m e ntation in the m e d ic
alre c
ord
as havingbe e n e valu ate d by the phys ic
ian.
Patient #10
k c
all 11/28/2013 for c
om plaint of a s e ve re
toothac
he . N o SO A P form at bu t ad e taile d narrative note. D ate /tim e , vitals igns and d u ration note d .
E valu ation ofm ou thand pote ntialtoothc
au s ingthe pain note d . T he phys ic
ian was c
ontac
te d by
te le phone and pain m e d ic
ation ord e rs re c
e ive d . T he re was no d oc
u m e ntation ofad e ntalre fe rral.
T he toothac
he protoc
olwas not re fe re nc
e d in the re c
ord . R N s ic
kc
all1/22/2014forc
om plaint of
le ft s hou ld e rpain fore ight m onths . A pre printe d protoc
olform was u s e d . D ate /tim e and ve ry brief
e xam ination and as s e s s m e nt note d . T he re no vitals igns note d . T he patient was provide d ove r-the c
ation thre e tim e s ad ay forthre e d ays .
Significant Issues with Nursing Sick Call

1. V iolation of the Illinois N u rs e P rac
tic
e A c
t for Lic
e ns e d P rac
tic
al N u rs e s (LP N s ) to
c
ond u c
t s ic
kc
alld u e to aphys ic
ale xam ination and as s e s s m e nt be ingre qu ire d whic
h is
be yond the s c
ope ofprac
tic
e foran LP N .
2. ID O C polic
y re qu ire s s ic
k c
all e nc
ou nte rs are d oc
u m e nte d in the Su bje c
t-O bje c
tive A s s e s s m e nt-P lan (SO A P )form at, whic
his not c
ons iste ntly u s e d .
3. D oc
u m e ntation is inc
ons iste nt and inc
om ple te , in that fre qu e ntly d ate s , tim e s , vitals igns ,
d u ration ofc
om plaint, e xam ination and as s e s s m e nt are not d oc
u m e nte d .
4. ID O C polic
y re qu ire s the u s e ofapprove d tre atm e nt protoc
ols in ord e rforaR N to c
ond u c
t
s ic
kc
all. Sic
kc
alle nc
ou nte rs are fre qu e ntly d oc
u m e nte d withno re fe re nc
e to aprotoc
ol.
5. P atients are only pe rm itte d one c
om plaint pe rs ic
kc
alle nc
ou nte r.
6. T he R N inad ve rte ntly pre s c
ribe d am e d ic
ine by inc
re as ingthe ove r-the -c
ou nte rd os age to
apre s c
ription d os age , whic
his pre s c
ribingand be yond the nu rs ings c
ope ofprac
tic
e.
7. P roble m s , like e arc
onge s tion, we re ne ve rad d re s s e d forone patient.
8. Som e patients are s e e n withou t e ithe ran ad e qu ate history orphys ic
9. D iffic
u lt to d ete rm ine if ac
c
e s s to s ic
kc
all is im pe d e d d u e to abroke n s ys te m or the
s ignific
ant nu m be rofhe althc
are u nit le ad e rs hipand nu rs ingpos ition vac
anc
ies .
Clinician Sick Call

B as e d on s e ve ral appointm e nt books give n to u s by the nu rs ings u pe rvisors , we s e le c
te d 12
appointm e nts d oc
u m e nte d as havingoc
c
u rre d . In 10ofthe 12re c
ord s , we c
ou ld ne ithe rfind anote
on the d ay the appointm e nt was writte n in the book norwithin awe e k be fore orafte rthat
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 13
d ate . It s e e m e d c
le arto u s that the re c
ord ke e ping, vis avis the appointm e nt books, was not ac
c
u rate
in the s e ns e that the patients who we re d oc
u m e nte d as havingbe e n s e e n by ac
linic
ian had no note s
in the irre c
ord s . T he re we re afe w e xc
e ptions .
Patient #1
T his is a37-ye ar-old who was s e e n on 12/10/13forrhe u m atoid arthritis follow u p. T he re we re no
note s in the re c
ord forthat. H owe ve r, on 12/11, the patient was s e e n forac
ys t withpu s c
om ing
ou t ofit. T he N P wrote an appropriate note and re fe rre d the patient to the phys ic
ian, who s aw the
patient on 12/17.
Patient #2
hronicproble m s . H e was to be s e e n foran as s e s s m e nt ofhis pain
m e d s on 12/19/13, bu t the re is no note forthat d ate.
Patient #3
T his is a22-ye ar-old s u ppos e d ly s e e n on 12/19/13 for bac
k pain, bu t the re we re no note s in his
re c
ord forthe m onthofD e c
e m be r.
Patient #4
T his is a47-ye ar-old m an withm u ltiple c
hronicd ise as e s . O n 6/21/13, the P A s aw the patient for
as e bac
e ou s c
ys t. H e d raine d and pac
ke d the c
ys t and re qu e s te d d aily d re s s ingc
hange s and follow
u pin two we e ks . T he re we re no d re s s ingc
hange s d oc
u m e nte d in the c
hart and the re was no followu pvisit d oc
u m e nte d at the two-we e k m ark. H e was ne xt s e e n on 7/31by aphys ic
ian, bu t the re is
no m e ntion ofthe wou nd s .
A t nu rs e s ic
kc
allon 9/24, the patient re qu e ste d to s e e aprovide rre gard inghis C O P D m e d ic
ations .
M D line was ord e re d for9/25, bu t the re is no note in the c
hart c
orre s pond ingto that d ate.
Patient #5
T his is a45-ye ar-old withm u ltiple iss u e s , inc
lu d ings e ve re re frac
tory tre m ors for whic
hhe has
s e e n in the ne u rology d e partm e nt at U IC . T he ir re c
om m e nd ation was for inc
re as ingd os e s of
K lonopin.
O n 12/12/13, he re qu e s te d to have his K lonopin inc
re as e d as re c
om m e nd e d by ne u rology and was
re fe rre d to the M e d ic
alD ire c
tor. She re ne we d the m e d ic
ation that d ay, bu t ne ithe r c
hange d the
d os e nors aw the patient. H e was s c
he d u le d fore valu ation on 12/26, bu t the re is no note from that
d ay.
O n 1/7/14, the R N d oc
u m e nte d that s he s poke to the ward e n abou t gettingthe patient in to s e e D r.
B , and was prom ise d that the patient wou ld be able to s e e the d oc
torthat M ond ay, bu t he was not
s e e n. H e finally d id s e e the phys ic
ian am onth late r on 2/13, and his m e d ic
ation was inc
re as e d .
T he re was no follow-u pnote as ofthe d ate ofou rvisit.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 14
Opinion:T his patient has not be e n s e e n tim e ly (orat all)in re s pons e to his re qu e s ts . T his patient
is hou s e d in the H e althC are U nit, m akinghim re ad ily ac
c
e s s ible to the provide rs . E ve n the nu rs e
s
atte m pt at inte rve ntion throu ghthe ward e n d id not re s u lt in the patient be ings e e n.
Patient #6
T his is an 86-ye ar-old m an withhype rte ns ion and history ofprostate c
anc
e rwho s aw his rad iation
onc
ologist on 7/23/13 in follow-u p of his prostate c
anc
e r. T he c
ons u ltant note d that the patient
re porte d ne w ons et re c
talble e d ingand re c
om m e nd e d c
olonos c
opy. W he n the patient s aw the ons ite
provide ron retu rn from this trip, the re c
om m e nd ation forc
olonos c
opy was bru s he d as ide withthe
e xplanation that the patient has e xternalhe m orrhoid s and anorm alhe m oglobin.
O n 10/22, the M D visits tam pwas c
ros s e d ou t and M D c
hart re viewwas writte n in. T he plan
was to s c
he d u le afollow-u pappointm e nt to e valu ate his he m orrhoids .
O n 11/6, the appointm e nt was c
anc
e lle d pe r M D re qu e stand re s c
he d u le d for11/18. O n 11/18,
the patient was s e e n forc
hronicc
are c
linic
. T he he m orrhoids and ble e d ingwe re not ad d re s s e d .
O n 12/4, the patient was s e e n on M D line fore valu ate throm bos is.T he patient re porte d ongoing
re c
talble e d ing. T he e xam s howe d only s m all e xte rnalhe m orrhoid and s toolwas ne gative for
blood . A nothe rC B C was ord ere d and was s table at 13.3.
Opinion:T his patient was not s e e n tim e ly for his c
om plaint of re c
tal ble e d ingnor has this
c
om plaint be e n thorou ghly e valu ate d . C onc
lu d ingthe he m orrhoid is the c
u lprit withou t e xc
lu d ing
m ore s e riou s pathology is not appropriate .

T he re was no way to d ete rm ine how m any inm ate s are e nrolle d in the c
hronicd ise as e c
linicat this
fac
ility, northe ind ivid u alc
linice nrollm e nts , as the s e are not trac
ke d in ac
om pre he ns ive , u pd ate d
and re liable way at this fac
ility.
T he re is no s ingle d e s ignate d c
hronicc
are nu rs e ;we we re told this is d u e to s taffings hortage s .
R athe r, e ac
h nu rs e is as s igne d as ingle c
hronicd ise as e c
linic
. T he re s u lt is afragm e nte d and
d isjointe d program withno c
ohe s ive ove rs ight. T he program is not be ingu tilize d e ffe c
tive ly;we
c
am e ac
ros s m any patients withc
hronicillne s s e s who we re not e nrolle d in the program and othe rs
who we re e nrolle d bu t not s e e n ac
c
ord ingto polic
y.
P atients withm u ltiple c
hronicillne s s e s are e nrolle d in the M IC or m u ltiple illne s s c
linic
. T he
c
linicnu rs e s c
oord inate the tim ingofthe c
hronicc
are c
linic
s withthe provid e rs . O nc
e d ate s for
c
linic
s are c
hos e n by the provide rs , the nu rs e s provid e that inform ation to the phle botom ist who
c
oord inate s the blood work withthe visits . Labs are to be d rawn within 30d ays priorto the visit
by polic
y.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 15
W e re viewe d five rand om re c
ord s ofpatients withhype rte ns ion and had c
onc
e rns withtim e line s s
and c
linic
ald e c
ision m akingin the thre e c
as e s d e s c
ribe d be low. In afou rthc
hart, the proble m list
had not be e n u pd ate d in ove r10ye ars .
Patient #1
T his is a74-ye ar-old withm u ltiple c
hronicillne s s e s , inc
lu d inghype rte ns ion, whos e c
are has be e n
c
om plic
ate d by his nonc
om plianc
e . T he only re c
e nt labin the c
hart is an e le c
trolyte pane lfrom a
ye arago. T he las t labte s t priorto that was in 2009.
O n 2/11/13, the patient was s e e n at M D s ic
kc
allforac
ou gh. H is blood pre s s u re was 156/90. T he
phys ic
ian wrote, State s he d oe s n
t ne e d to s e e m e . P roble m re s olve d . T he blood pre s s u re was
not ad d re s s e d .
D u ringan offs ite visit to U IC onc
ology on 2/23, the patient
s blood pre s s u re was 194/108. H e was
give n ad os e ofC lonid ine by the onc
ology re s id e nt. T he re was no follow-u pofthe blood pre s s u re
afte rhis re tu rn to the ins titu tion.
hronicc
are c
linicfor hype rte ns ion, d iabe te s and as thm a. T he phys ic
ian
note d nonc
om plianc
e with tre atm e nt and re fu s als to have labs d rawn. E d u c
ation was provide d .
T he re we re no fu rthe rc
hronicc
linicnote s as ofthe d ate ofou rvisit.
Opinion:T his patient is ove rd u e forc
hronicc
are c
linic
. H is e le vate d blood pre s s u re has not be e n
ad e qu ate ly ad d re s s e d . Fu rthe ratte m pts s hou ld be m ad e to e nhanc
e this patient
sc
om plianc
e.
Patient #2
T his is a69-ye ar-old m an withoxyge n d e pe nd e nt C O P D , c
oronary arte ry d ise as e withhistory of
M I, hype rte ns ion and he aringim pairm e nt who arrive d at D ixon on 6/11/13. H is m e d ic
ations
inc
lu d e an A C E inhibitorand as pirin.
H is c
hronicd ise as e bas e line c
linicwas on 7/19. Labs we re d rawn tim e ly priorto the visit and his
blood pre s s u re was we llc
ontrolle d .
T he ne xt c
hronicc
are c
linicwas on 10/11. T he re we re no ne w labs . T he patient
s blood pre s s u re
was 160/80 and blood pre s s u re c
he c
ks we re ord e re d . T he s e we re not in the c
hart, nor we re
s u bs e qu e nt c
hange s m ad e to his m e d ic
ation. Follow-u pwiththe nu rs e prac
titione rwas ord e re d for
thre e we e ks late rbu t d id not oc
c
u r.
A t the ne xt c
hronicc
are c
linicon 2/6/14, the provid e r note d that nitroglyc
e rin he lps with his
angina.T he re we re no othe rd etails abou t the natu re ofhis c
he s t pain and no fu rthe rinve s tigation
was ord e re d . H is blood pre s s u re was 158/80and the A C E inhibitorwas inc
re as e d .
Opinion:T his high-risk patient
s re port of angina ne e d s to be inve s tigate d thorou ghly. H is
c
oronary arte ry d ise as e has not be e n m anage d ac
c
ord ingto c
u rre nt gu ide line s , whic
h wou ld
inc
lu d e a be ta-bloc
ke r and s tatin. H is blood pres s u re s hou ld be m onitore d and tre ate d m ore
d ilige ntly.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 16
Patient #3
T his is an 86-ye ar-old m an with hype rte ns ion and history of prostate c
anc
e r. H is m e d ic
ations
inc
lu d e d as pirin, potas s iu m , hyd roc
hlorothiaz id e and m e toprolol. A t his 3/11/13 c
hronicc
are
c
linic
, his c
ard iace xam was d e s c
ribe d as irre gu larly irre gu lar, bu t no E C G was obtaine d . H is
blood pre s s u re was e le vate d and m e d ic
ation was pre s c
ribe d . Labs we re d one tim e ly priorto this
visit.
H is ne xt c
hronicc
are c
linicoc
c
u rre d s ix m onths late ron 9/23. N o ne w labs we re obtaine d . H is
c
ard iace xam was d e s c
ribe d as R SR [re gu lars inu s rhythm ]withfe w irre gbe ats .A gain, no E C G
was obtaine d . B lood pre s s u re was we llc
ontrolle d .
T he ne xt c
hronicc
are visit was on 11/18. T his tim e his c
ard iace xam was , rs rwithrare e c
topic
be at.T he re we re no re c
e nt labs .
Opinion:T his patient has not be e n s e e n tim e ly in c
hronicc
are c
linicand his e le c
trolyte s have not
be e n c
he c
ke d in ove raye ar. Irre gu larhe art rhythm s s hou ld be inve s tigate d withan E C G.
HIV Infection/AIDS
R e view ofthe H IV c
linicre ve ale d that the ID te le m e d ic
ine visits d o not always oc
c
u rtim e ly and
the re ports we re not c
ons iste ntly file d in the he althre c
ord . T he ons ite provide rs d o not partic
ipate
in m onitoringpatients H IV d ise as e at this fac
ility. W hile we wou ld not e xpe c
t the m to be fac
ile
in pre s c
ribingH IV m e d ic
ations , we wou ld e xpe c
t that the y wou ld partic
ipate in m onitoring
patients m e d ic
ation c
om plianc
e , s ide e ffe c
ts and ge ne rald e gre e ofd ise as e c
ontrol.
T he c
as e be low e xe m plifies the type s ofiss u e s we obs e rve d at this fac
ility:
Patient #4
T his is a47-ye ar-old m an with m u ltiple c
lu d ingad vanc
e d H IV d ise as e on
s alvage the rapy. W he n he was s e e n by ID te le m e d ic
ine in Janu ary 2013, the e le c
tronics tethos c
ope
was broke n. H is re gim e n was c
hange d d u e to c
onc
erns ove rpote ntiald ru ginte rac
tions and athre em onthfollow-u pwas re qu e ste d withblood work prior. T he re we re no on-s ite provide rnote s afte r
this to m onitorthe patient fors ide e ffe c
ts , c
om plianc
e ortole rability.
W he n he s aw ID again in A pril, the e le c
tronics te thos c
ope was stillbroke n. T he patient re porte d
havingm iss e d 2-3d os e s ofm e d ic
ation. Labs we re not d one priorto this visit;this ove rs ight was
partic
u larly c
ru c
ialgive n the re c
e nt c
hange in the rapy. It d oe s not appe arthat the labs we re d rawn
afte rthe visit e ithe r, as the ne xt s et oflabs was d ate d 7/8/13. A 3-m onthfollow u pwas re qu e ste d
bu t he was not s e e n again u ntilSe pte m be rac
c
ord ingto the nu rs e
s note ;the re was no re port in the
he althre c
ord .
A t his ne xt ID te le m e d ic
ine visit on 11/15/13 he was d oing we ll and no c
hange s we re
re c
om m e nd e d . H e was ne xt s e e n on 2/20/14bu t the re was no re port in the c
hart.
T he re are no c
hronicc
are form s in the c
hart. T he only provid e rs m anagingthis patient
s c
hronic
illne s s e s are the offs ite s pe c
ialists .
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 17
Opinion:T his patient has had no on s ite m onitoringofhis H IV d ise as e , m e d ic

ation c
om plianc
e or
s id e e ffe c
ts . H is ID c
linicvisits have not always be e n tim e ly and re ports from the c
ons u ltant have
not be e n c
ons iste ntly obtaine d .
Pulmonary
W e re viewe d s e ve n re c
ord s of patients with pu lm onary d ise as e , bu t only two appe are d to be
e nrolle d in the pu lm onary c
linic
. O fthos e two c
as e s , one was proble m atic(P atient #1be low). O f
the re m ainingc
as e s , only two m e ntione d (bu t d id not ad d re s s )the patients C O P D .
Patient #5
T his is a69-ye ar-old m an withoxyge n d e pe nd e nt C O P D , c
oronary arte ry d ise as e withhistory of
M I, hype rte ns ion and he aringim pairm e nt who arrive d at D ixon on 6/11/13.
A t his bas e line c
linicon 7/19, his pe ak flow was low at 250and his inhale rs we re ad ju s te d . A t his
ne xt c
hronicc
are c
linicon 10/11, he had rhonc
hiin bothlowe rlobe s and his pe ak flow was ve ry
low at 150. A third inhale rwas ad d e d , bu t no othe rworku portre atm e nt was ord ere d forthe C O P D
e xac
e rbation, norwas he d iagnos e d withs u c
h. Follow-u pwiththe nu rs e prac
titione rwas ord e re d
forthre e we e ks bu t d id not oc
c
u r.
O n 1/6/14, he was s e e n at nu rs e s ic
kc
allforac
old .T he patient re porte d s hortne s s ofbre athon
e xe rtion and aprod u c
tive c
ou gh. T he nu rs e note d d e c
re as e d lu ngs ou nd s on e xam . T he re we re no
vitals d oc
u m e nte d and no pe ak flow. T he nu rs e d e c
ide d that he had ac
old and gave him an ove rthe -c
ou nte rre m e d y. T he re was no re fe rralto aprovid e r.
T e n d ays late r, the patient re tu rne d withd iffic
u lty bre athing. H e was s e e n by an R N , who note d
that his bre athings e e m e d u nlabore d . T he re was no lu nge xam d oc
u m e nte d . T he as s e s s m e nt was
ille gible , and the plan was to m anage s ym ptom s . U s e inhale rs as pre s c
ribe d .
O n 1/21, he was s e e n on M D line forfollow u pofhype rte ns ion and C O P D . H e re porte d whe e z ing
d aily in the m orningand c
om plaine d that his s hortne s s ofbre athwas ge ttingwors e . T he re was
no pu ls e oxim e try and no pe ak flow m e as u re m e nt. T he lu ngs we re d e s c
ribe d as c
le ar. T he d oc
tor
ord e re d nitroglyc
e rin as ne e d e d and ne bu lize rtre atm e nts d aily as ne e d e d forone ye ar.
hronicc
are c
linic
. H is pe ak flow was low at 270. H is C O P D was not
e valu ate d fu rthe rand no m e d ic
ation c
hange s we re m ad e .
Opinion:A lthou ghthis patient has be e n s e e n in c
hronicc
are c
linicac
c
ord ingto polic
y, his d ise as e
has not be e n m onitore d orm anage d ad e qu ate ly. N u rs ingas s e s s m e nts we re inad e qu ate and nu rs ing
s tafffaile d to re fe rthe patient to aprovide rwhe n appropriate .
Patient #6
T his is a47-ye ar-old m an with m u ltiple c
lu d ingC O P D , ye t the re we re no
c
hronicc
are form s in this patient
sc
hart.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 18
T he firs t provid e rvisit s inc

e Janu ary 2013was d ate d 6/2/13and foc
u s e d m ainly on the patient
s
anxiety abou t be ingm ove d to afou rpatient room and his risk forc
atc
hingan illne s s .
A t nu rs e s ic
kc
allon 9/24, the patient re qu e ste d to s e e aprovide rre gard inghis C O P D m e d ic
ations .
M D line was ord e re d for9/25, bu t the re is no note in the c
hart c
orre s pond ingto that d ate.
O n 10/8, he s aw the nu rs e prac
titione r re gard ingd iffic
u lty trans portingwiththe blac
k box. N o
c
hronicc
ond itions we re ad d re s s e d and the re we re no fu rthe rprovide rnote s in the c
hart.
Opinion: T his patient
s C O P D has not be e n ad d re s s e d in m ore than aye ar, d e s pite his re qu e s t.
Patient #7
T his is a55-ye ar-old m an whos e proble m list inc
lu d e s only d e pre s s ion withs u ic
id alid e ation. H e
e vid e ntly als o has anoxicbrain inju ry and m od e rate C O P D ac
c
ord ingto apu lm onary fu nc
tion te s t
d ate d Ju ly 2013. T he re are no c
hronicc
are form s in the c
hart. T he re is only one m e ntion ofC O P D ;
on 8/2/13, the patient was s e e n on M D line for C O P D follow-u p, bu t this was ne ve r ad d re s s e d .
Ins te ad , the visit foc
u s e d on the patient
s bac
k pain. A lthou ghhe was s e e n m u ltiple tim e s ove rthe
ne xt fe w m onths forbac
k pain, his C O P D was ne ve rad d re s s e d .
Seizure Disorder
W e re viewe d five re c
ord s of patients with s e izu re d isord ers . T wo patients d id not appe ar to be
e nrolle d in the s e izu re c
linic
, and anothe rc
as e was s ignific
antly proble m aticas d e s c
ribe d be low.
Patient #8
T his is a70-ye ar-old m an withs e izu re s , as thm a, he patitis C , c
oronary arte ry d ise as e , late nt T B
infe c
tion and s c
hizophre nia.
O n 9/1/13, the R N re s pond e d to the u nit afte rthe patient had as e izu re . T he patient re fu s e d to c
om e
to the he althc
are u nit, so the nu rs e allowe d him to re st in his c
e ll, notingthat the C O willc
he c
k
1
on him in /2 hou r.T hirty m inu te s late r, the re is an R N note statingno e nc
ou nte r. Spoke with
sec
u rity on H R 3. IM O live rs le e pings ou nd ly on his be d . Side lyingpos ition.T he re is no m e ntion
ofc
allingaprovide r. O fnote, the patient had had as u bthe rape u ticT e gretolle ve l(3.4)on 8/7. T he
labre port was s igne d by aprovide ron 8/8, bu t no c
hange s we re m ad e . T he M A R s hows that the
patient had be e n c
om pliant withhis m e d ic
ation.
O n 9/5, anote s tam pe d nu rs e s ic
kc
alls tate s only, alre ad y on M D line .T he M e d ic
alD ire c
tor
s aw the patient this d ay foram e d ic
alwrit follow-u p, bu t the re is no m e ntion ofthe re c
e nt s e izu re .
O n 1/22, the patient was s e e n in c
hronicc
are c
linic
. H e re porte d havingone s e izu re s inc
e the las t
c
linic
. H is T e gre tolle ve lhad las t be e n m e as u re d on 12/3 and was the rape u ticat that tim e . N o
m e d ic
ation c
T wo d ays late r, the patient had awitne s s e d s e izu re and was re fe rre d to the d oc
torthat d ay. T he
d oc
tornote d that his m os t re c
e nt priors e izu re was in N ove m be r2013, bu t the re is no
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 19
d oc
u m e ntation in the c
hart to that e ffe c
t. T he phys ic
ian inc
re as e d the T e gre told os e and ord e re d a
le ve lto be d rawn in two we e ks . T he le ve lwas d rawn on 2/7 and was not s ignific
antly d iffe re nt
from the las t valu e .
Opinion:It is not appropriate to e xpe c
t sec
u rity s taffto pe rform m e d ic
alm onitoringofapost-ic
tal
patient. T he nu rs e s hou ld have gone bac
k to the u nitto m onitorthe patient and s hou ld have re fe rre d
the patient to aprovid e rforfollow-u p. E ve n whe n the patient late rd id s e e aprovid e r, the d oc
tor
d id not ad d re s s the re c
e nt bre akthrou ghs e izu re . It appe ars that this patient
s s e izu re d isord e ris not
ad e qu ate ly c
ontrolle d by the m e d ic
ation he is pre s c
ribe d .
Patient #9
T his is a65-ye ar-old m an with s e izu re s , hype rte ns ion and as thm a. A t the 1/23/13 c
hronicc
are
c
linic
, he re porte d that he had ru n ou t of his s e izu re m e d ic
ation. H is las t s e izu re was not
d oc
u m e nte d . T he re was no s u bje c
tive inform ation;this was partly d u e to the s tru c
tu re of the
c
hronicc
are form , whic
hhas not be e n u pd ate d in ove r 10 ye ars (2002). Labs we re d one tim e ly
priorto the visit (1/17).
A t the 7/8/13c
hronicc
are c
linicvisit, the re had be e n no inte rim s e izu re ac
tivity s inc
e the las t visit.
T he m os t re c
e nt labs had be e n d one in M ay.
O n 10/1, it is note d that the patient s igne d offfrom c
hronicc
are c
linic
. Labs d one 9/18s howe d
as u bthe rape u ticD ilantin le ve lat 3.9.
Opinion:It is not c
le arwhat s igne d offfrom c
hronicc
are c
linicm e ans , othe rthan to im ply that
the patient has d ise nrolle d him s e lf. T his d oe s not s e e m appropriate , give n that he c
ontinu e s to
re c
e ive tre atm e nt fors e izu re s . T he re as ons be hind his ru nningou t ofm e d ic
ation are not c
le ar, and
his s u bthe rape u ticm e d ic
ation le ve lhas not be e n pu rs u e d .
TB Infection Clinic
A t the tim e ofou r visit, the re we re fou r patients e nrolle d in this c
linic
. T wo ofthe fou r patients
we re s tarte d on tre atm e nt at D ixon;the othe rtwo arrive d alre ad y on the rapy. In none ofthe fou r
c
harts d id the tre atingprovide rd oc
u m e nt as ym ptom as s e s s m e nt priorto initiatingthe rapy. O ne
patient had no re c
e nt labs in his c
hart d e s pite be ginningthe rapy ove r two m onths prior. T wo of
the fou rre c
ord s had no bas e line c
he s t x-ray in the file .
N one ofthe patients had M A R s file d in the ir c
harts. T he re is no m e c
hanism in plac
e to ale rt the
c
hronicc
are nu rs e (or anyone e ls e )whe n patients m iss d os e s . M iss e d d os e s are only re c
ognize d
d u ringthe m onthly R N visit, thou ghthis is highly d ou btfu l, as the M A R s forallthe patients we re
in giant pile s ofloos e filingd atingbac
k form onths in the m e d ic
alre c
ord s offic
e . W e fou nd five
pile s ofM A R s , e ac
hat le as t one foot high. It was c
le ar from ou r c
hart re views that the c
hronic
d ise as e nu rs e is not we llinform e d abou t the statu s ofpatients m e d ic
ation c
om plianc
e.
O ne patient had m iss e d thre e ofhis las t e ight d os e s ;anothe r inform e d the c
hronicd ise as e nu rs e
that he had s toppe d the rapy e ntire ly two we e ks pre viou s ly afte rs pe akingwithone ofthe provide rs .
N o su c
hc
onve rs ation was d oc
u m e nte d in the he althre c
ord . In anothe rc
as e , the T B
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 20
c
linicnu rs e note d that the patient had afe w m iss e d d os e s , ye t re view ofthe M A R d id not s u pport
this c
laim .
B os we llP harm ac
e u tic
als , loc
ou nte r
m e d ic
ations for the fac
e is a fax and fill s ys te m , whic
h m e ans patient
pre s c
riptions faxe d to the pharm ac
y tod ay by agive n c
u t-offtim e willarrive at the fac
ility the ne xt
d ay. P atient s pe c
ificpre s c
riptions , s toc
k pre s c
riptions and c
ontrolle d m e d ic
ations arrive pac
kage d
in a31-d ay bu bble pac
k. O ve r-the -c
ou nte r m e d ic
ations are provide d in bu lk by the bottle , tu be ,
e tc
. A loc
albac
k-u ppharm ac
y is u s e d to obtain m e d ic
ation whic
his ne e d e d im m e d iate ly and is
not available in s toc
k.
T he m e d ic
ation pre paration/storage are ais s taffe d withfou rpharm ac
y te c
hnic
ians , thre e c
ontrac
t
and one s tate e m ploye d , and B os we llprovid e s ac
ons u ltingpharm ac
ist to c
om e on-s ite onc
e a
m onthto re view pre s c
ription ac
tivity, to as s e s s pharm ac
y te c
hnic
ian pe rform anc
e and te c
hniqu e
and to d e stroy ou td ate d orno longe rne e d e d c
ontrolle d m e d ic
ations pu rs u ant to the re qu ire m e nts
ofthe Fe d e ralD ru gA d m inistration (FD A )and D ru gE nforc
e m e nt A ge nc
y (D E A ).
Ins pe c
tion ofthe m e d ic
ation pre paration/storage are are ve ale d ave ry large , c
le an, we ll-lighte d and
ge ne rally we ll-m aintaine d are a. A n inte rview withthe c
hiefte c
hnic
ian re ve ale d aknowle d ge able
ind ivid u alwith m any ye ars workingas apharm ac
y te c
hnic
ian. Ins pe c
tion ofthe are aind ic
ate d
tight ac
c
ou nting of c
ontrolle d m e d ic
ations , both s toc
k and re tu rn ite m s , ne e d le s /syringe s ,
s harps /ins tru m e nts and m e d ic
altools . A rand om ins pe c
tion of pe rpetu alinve ntories and c
ou nts
ind ic
ate d allwe re c
orre c
t.
M e d ic
ation ad m inistration c
ons ists oftwo m e thod s . W ithm e thod 1, m e d ic
ation is ad m iniste re d at
c
e ll-s id e . W ith m e thod 2, inm ate s m ove in large line s to the H e alth C are U nit to re c
e ive the ir
m e d ic
ation. T he fac
ility c
ontinu e s to u s e apape rm e d ic
ord (M A R ), and
e ac
hd os e ofm e d ic
ation ad m iniste re d orre fu s e d is note d on the patient s pe c
ificM A R .
O bs e rvation ofm e thod 1re ve ale d m e d ic
ation ad m inistration by aLic
e ns e d P rac
tic
alN u rs e (LP N ),
who prope rly id e ntified the patients , ad m iniste re d the m e d ic
ation throu ghafood s lot port in the
s olid c
e ll d oor, obs e rve d the inge s tion, pe rform e d a m ou th c
he c
k and d oc
u m e nte d the
ad m inistration on the M A R . A s e c
u rity offic
e r was obs e rve d e s c
orting the LP N d u ring
ad m inistration.
Laboratory
Laboratory s e rvic
c
e s m e d ic
alc
ontrac
torprovid e s one FT E phle botom ist to d raw and pre pare
the s am ple s for trans port to U IC . R e s u lts are ele c
tronic
k to the fac
ility,
ge ne rally, within 24 hou rs vias e c
u re fax line loc
ald e partm e nt. T he re we re no
e.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 21
Unscheduled Services/Emergency Services

In ord e rto re view u ns c
e s , we typic
ally atte m pt to re view bothu ns c
he d u le d ons ite
s e rvic
e s and u ns c
e s . D ixon was not able to provid e alogbook that had e ithe r
type ofs e rvic
e trac
ke d ove rtim e . T he re fore , it was c
le ar the y we re u nable to pe rform any s e lfm onitoring. T he y d id not e ve n have available alogofoffs ite or e m e rge nc
y s e nd ou ts . T he only
thingthe y c
ou ld provide u s was inc
id e nt re ports from the las t thre e m onths . H owe ve r, it appe are d
that the inc
id e nt re ports we re inc
om ple te . W e re viewe d s ix ons ite e m e rge nc
ies and fou re m e rge ncy
s e nd ou ts. A llofthe e m e rge nc
y s e rvic
es c
ontaine d proble m s , the m os t c
om m on ofwhic
hwas that
the ins titu tion ne ve rre c
e ive d e ithe re m e rge nc
y room re ports forthos e s e nt ju s t to the e m e rge ncy
room or hos pitald isc
harge s u m m aries for thos e ad m itte d to the hos pital. T his c
om prom ise s the
ability of the c
linic
ians to u nd e rs tand what s e rvic
e s we re provide d and what the bas is for any
re c
om m e nd ations m ight be .
Patient #1
T his is a 69-ye ar-old with hype rte ns ion, hypothyroid ism and s tatu s post trac
he os tom y. O n
11/26/13, ac
od e 3was c
alle d in the x-ray d e partm e nt at the fac
ility. A ppare ntly, the inm ate was
havingd iffic
u lty bre athingd u e to his trac
he os tom y be ingplu gge d . T he trac
he os tom y was c
le ane d
and the patient was s e nt bac
k to the hou s ingu nit. T he re is no as s e s s m e nt ord isc
u s s ion withany
ad vanc
e d le ve lc
linic
ian, only abriefnote by an LP N . T he patient was not s e e n by an ad vanc
ed
le ve lc
linic
ian u ntilm ore than awe e k late r.
Patient #2
T his is a48-ye ar-old withs e izu re d isord e r. O n 1/1/14, anu rs e was c
alle d to the hou s ingu nit fora
c
od e 3. In the re c
ord the re is no d e s c
ription ofthe e ve nt, bu t the patient was brou ght to the c
linic
and u ltim ate ly wante d to retu rn to the hou s ingu nit. T he only note in the re c
ord is anote by an
LP N whe re the as s e s s m e nt re ad s , pos t s e izu re .T he patient was retu rne d to the hou s ingu nit by
the LP N withno c
ontac
t withan ad vanc
e d le ve lc
linic
ian. T he re was an inad e qu ate history and
phys ic
al as s e s s m e nt s inc
e only an LP N s aw the patient, and the re we re s ignific
ant liabilities
e nge nd e re d by this re s pons e .
Patient #3
T his is a57-ye ar-old who has apos itive tu be rc
u los is s kin te s t bu t has be e n tre ate d and als o has a
s e izu re d isord e r, asthm aand bipolard isord e r. O n 10/31/13at abou t 12:15p.m ., ac
od e 3was c
alle d
withthe inm ate c
om plainingofc
he s t pain. T he re is an inad e qu ate as s e s s m e nt pe rform e d by an R N
who ind ic
ate s that the inm ate s tate s , I
m worried abou t goingou t in fou rm onths .T he vitals igns
we re norm al and the inm ate is d e s c
ribe d as hold inghis c
he s t. T he history is inad e qu ate . T he
as s e s s m e nt is c
he s t vs . anxiety. Sinc
e the patient ind ic
ate d he fe lt be tte r, the as s e s s m e nt was
ru le ou t anxiety and the patient was re le as e d to the hou s ingu nit. C he s t pain s hou ld always
re qu ire an as s e s s m e nt by an ad vanc
e d le ve lc
linic
ian.
Patient #4
T his is a27-ye ar-old withm e ntalhe althproble m s . O n 1/6/14, ac
od e 3was c
alle d and the patient
was brou ght to the he althc
are u nit. T he inm ate had be e n fou nd u nre s pons ive in his c
e ll, lyingon the
floor and havingase izu re. W he n the y e nte re d the c
e ll, he was still je rkingor twitc
hingon the
m attre s s. H e state d he inte ntionally hit his he ad on the wall. O n 1/7/14, he is d e s c
ribe d as having
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 22
had as ync
opale pisod e bu t the re is no as s e s s m e nt. The patient was s e e n late rby anu rs e prac
titione r
bu t the re was no d isc
u s s ion ofthe e pisod e oc
c
u rringone d ay e arlier.
Patient #5
T his is a42-ye ar-old withhype rlipid e m ia. A c
od e 3 was c
alle d on 11/25/13 be c
au s e the inm ate
was fou nd lyingon the s id e walk ou ts id e ofhis hou s ingu nit. H e had told anu rs e that he had worke d
ou t in the gym , be c
am e d izz y and s at d own. W he n he s tood u pqu ic
kly he got d izz y again and the n
lay d own on the s id e walk. T he nu rs e pe rform e d vitals igns on the s ide walk and s inc
e the y we re
norm al, re le as e d him to the hou s ingu nit. T he re was no follow u ppe rform e d and he was not s e e n
again u ntilm ore than am onthlate rin his re gu larhype rte ns ion c
linic
;howe ve r, the inc
id e nt with
the e pisod e s ofd izz ine s s was ne ve rd isc
u ssed .
Patient #6
T his is a53-ye ar-old withhype rte ns ion and type 2d iabe te s alongwithhe patitis C . O n 12/7/13, a
c
od e 3was c
alle d in d ietary. W he n the y arrive d the patient ind ic
ate d , M y kne e gave ou t.H e was
plac
e d in the infirm ary forobs e rvation and re le as e d s hortly the re afte r. T he re has be e n no phys ic
ian
as s e s s m e nt re gard ingthis s itu ation.
Patient #7
T his is a68-ye ar-old withm e ntalhe althproble m s and as thm a. O n 10/25/13, at abou t 12:40p.m .,
ac
od e 3was c
alle d and whe n the nu rs e arrive d the patient was walkingto avan ac
c
om panied by
c
orre c
tionaloffic
e rs . H e c
ou ld be he ard whe e z ingand he was obs e rve d to be u s inghis inhale r.
T he nu rs e pe rform e d apu ls e oxim e te rre ad ing, whic
hwas 85% . T he patient was take n to the he alth
c
are u nit and was s e e n by the phys ic
ian, who ord e re d bothorals te roids and inhale d s te roids . T his
patient has ne ve rbe e n followe d u pon.
Patient #8
T his is a35-ye ar-old withm e ntalhe althproble m s . O n 11/3/13, ac
od e 3was c
alle d and the patient
was fou nd withblood on the floor from alac
e ration on his he ad . W hile be ingtrans porte d to the
m e d ic
alu nit, he was note d to have proje c
tile vom itingand the re fore was s e nt to the hos pital. O n
11/5, two d ays late r, he retu rne d withthe hos pitald iagnos is, patient ind u c
e d hyponatre m iac
au s ing
s e izu re s .T he patient was ad m itte d to the infirm ary d ry c
e ll. T he re were no hos pitalre c
ord s in the
m e d ic
alre c
ord and on 11/12he was d isc
harge d to his hou s ingu nit.
Scheduled Offsite Services

W e we re inform e d that the proc
e s s for ac
c
om plishingas c
e inc
lu d e s , onc
e
the phys ic
ian orad vanc
e d le ve lprovid e rord ers the s e rvic
e, su c
has ac
ons u ltation orproc
e d u re ,
the ac
tingM e d ic
alD ire c
torre views the re qu e s t and the n pre s e nts it at awe e kly c
olle gialre view
withW e xford c
e ntraloffic
e phys ic
ian s taffwho work forthe iru tilization m anage m e nt program .
E ac
hc
as e is d isc
u s s e d and the re is e ithe r an approvaloran alte rnate plan is re c
om m e nd e d . T he
alte rnate plan m ay re s u lt in s om e ad d itionalte s ts to be d one be fore the ord e re d s e rvic
e is provide d .
O nc
e the W e xford c
e ntral offic
e phys ic
ian has approve d the s e rvic
e ove r the te le phone , this
u tilization m anage m e nt program is re s pons ible forprovid ingan au thorization nu m be rattac
he d to
the approve d s e rvic
e and the n notifyingthe U nive rs ity ofIllinois at C hic
ago s c
he d u le r, who the n
willprovid e an appointm e nt and notify the D ixon C orre c
tionalC e nte r
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 23
sc
he d u le r. W e fou nd that the re we re le ngthy d e lays in this proc
e s s , s om e tim e s d u e to as u bs tantial
d e lay be twe e n the ve rbalapprovalove rthe phone and the notific
ation to the U nive rs ity ofIllinois
sc
he d u le r and s om e tim e s , ad d e d to that, is ad e lay bas e d on the U nive rs ity ofIllinois not be ing
able to tim e ly provid e an appointm e nt. A bou t 10-15% of s c
e s are finally
obtaine d loc
ally be c
au s e this c
an be ac
c
om plishe d m ore rapid ly. T he c
u rre nt trac
kinglogd oe s not
inc
lu d e d ate oford e rnord ate ofappointm e nt, s o that the le ngthoftim e be twe e n the re qu e s t, the
au thorization and the appointm e nt c
annot be visu ally re viewe d in an e ffic
ient m anne r. A ls o, the re
are oc
c
as ions whe n an approvalis provide d bu t this s c
he d u lingproc
e s s ge ts d e laye d to s u c
han
e xte nt that the n ane w re qu e s t m u s t be c
re ate d . A ny s ys te m that allows e ffic
ient as s e s s m e nt ofa
sc
e program s hou ld have the d ate oford er, the d ate ofau thorization, the d ate
ofthe appointm e nt and the d ate ofthe prim ary c
are c
linic
ian follow u pwiththe patient in atrac
king
log.
ord s ofpatients forwhom ac
linic
ian had ord e re d as c
e.
E ight of11 we re proble m atic
, e ithe r d u e to d e lays or d u e to lac
k ofc
ritic
alfollow u p withthe
patient.
Patient #1
T his is a65-ye ar-old m ale with hype rte ns ion, as thm a, GE R D , and apos itive T B s kin te s t. O n
11/20/13, the c
linic
ian ord e re d aC T s c
an ofthe c
he s t to ru le ou t am as s . T his patient was pre s e nte d
at the c
olle gialre view alittle ove rtwo we e ks late r, on 12/4, and an approvalwas obtaine d . T hre e
we e ks late r the au thorization nu m be r was provid e d . T he re port d one on 2/12/14 ind ic
ate s
s u s pic
iou s forc
anc
e r. A re qu e s t forapu lm onary c
ons u lt was m ad e and approve d ove rtwo we e ks
ago and ye t an au thorization nu m be rforthis has s tillnot be e n provide d .
Patient #2
T his is a47-ye ar-old m ale withno c
hronicproble m s . O n 11/13/13, abone s c
an was ord e re d d u e
to apriorre port d e m ons tratingbilate rald e ns ities in the ile acare as . T he au thorization was provide d
on 12/20 and ye t the U nive rs ity of Illinois s c
he d u le r ind ic
ate s that s he has re c
e ive d no
c
om m u nic
ation from the W e xford c
e ntraloffic
e , s o the re is no appointm e nt d ate provide d .
Patient #3
T his is a62-ye ar-old m ale with hype rte ns ion, d iabe te s type 2, c
onge s tive he art failu re , gou t, a
pac
e m ake r, obs tru c
tive s le e papne aand c
ard iom yopathy. A n appointm e nt forthe c
ard iology c
linic
was ord e re d on 10/2/13. T he patient was finally s e e n on 2/14/14, fou rm onths late r.
Patient #4
T his is a64-ye ar-old withhype rte ns ion, d iabe te s type 2and as oft tiss u e m as s . O n 10/8/13, a30d ay E K G m onitor was ord e re d bas e d on aprior c
ard iology re c
om m e nd ation. T his s e rvic
e was
au thorize d on 10/24. T he patient was s e nt bac
k to c
ard iology on 1/28/14, whic
hre -re c
om m e nd e d
the E K G m onitor, bu t this has not ye t oc
c
u rre d , alm os t halfaye arlate r.
Patient #5
T his is apatient withhype rte ns ion and he patitis C alongwithahistory ofapos itive T B s kin te st.
O n 11/7/13, an ortho c
linicappointm e nt was ord ere d . It was au thorize d within as hort pe riod of
tim e , bu t as ye t it has not be e n s c
he d u le d .
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 24
Patient #6
T his is a46-ye ar-old witham as s in his jaw. H e als o has ablind right e ye and an ortho appointm e nt
was ord ere d on 9/12/13. T he c
olle gial re view oc
c
u rre d two we e ks late r on 9/25, bu t it was
re c
om m e nd e d that an u ltras ou nd be obtaine d priorto the ortho appointm e nt. T he u ltras ou nd was
ord ere d and approve d on 10/16and pe rform e d on 11/13. T he d oc
tord isc
u s s e d the c
as e withthe
patient and the n re ord e re d the orthope d ice valu ation. T his was au thorize d on 11/27, bu t as ofye t
the appointm e nt has not oc
c
u rre d .
Patient #7
T his is a 58-ye ar-old m ale with an e nlarge d pros tate and apos itive T B s kin te s t. A u rology
appointm e nt was ord e re d on 7/30/13 and it was au thorize d on 8/7. T he appointm e nt has be e n
sc
he d u le d now for3/12/14. T his is an e xtre m e ly longd e lay.
Patient #8
T his is a66-ye ar-old m ale withhype rte ns ion forwhom as tre s s te s t was ord e re d on 11/12/13, bas e d
on ac
ard iology re c
om m e nd ation. T he s tre s s te s t was au thorize d on 12/27;howe ve r, the patient
has s tillnot be e n s e e n. T he re has as ofye t be e n no c
om m u nic
ation to the U nive rs ity ofIllinois
from W e xford .
Patient #9
T his is a45-ye ar-old withhype rte ns ion, s e ve re trem ors and as e izu re d isord e r. H e has be e n s e e n
by U IC ne u rology who has re c
om m e nd e d inc
re as ingd os e s ofK lonopin (u pto 4m gtwic
e ad ay)
and othe r m e d ic
ations , bu t nothings e e m s to c
ontrol his tre m ors . N e u rology has not m ad e a
d e finitive d iagnos is;at one visit, his c
ond ition is d e s c
ribe d as non P arkins onian tre m or, at
anothe rtre m orwithP arkins onian fe atu re s .T he patient was s e e n in Fe bru ary and M ay of2013;
re qu e s t for follow-u p visit was d e nied in A u gu s t. T he alte rnate plan was to c
ontinu e to follow
and tre at ons ite . R e pre s e nt in thre e m onths . M e anwhile , the patient c
ontinu e s to fallfre qu e ntly
and m u s t be pe rm ane ntly hou s e d in the he althc
are u nit.
Opinion: T his patient s till d oe s not have a c
le ar d iagnos is and tre atm e nt re s pons e has be e n
s u boptim al. W e inte rviewe d this patient d u ringou r visit. C ons ide ringthe s e ve rity ofhis tre m or,
the d e gre e of his d isability and his you ngage , we wou ld re c
om m e nd e ithe r follow u p with
ne u rology, a s e c
ond ne u rologist
s opinion, or a trial of tre atm e nt for e s s e ntial tre m or be
u nd e rtake n, s u c
has propranololorprim id one ifnot alre ad y tried .
Infirmary Care
T he d e s ignate d infirm ary is loc
ate d on the s e c
ond floorofthe m e d ic
albu ild ing. T he re are 28total
be d s withpatient c
e ns u s of22 d u ringthe ins pe c
tion. O fthe 22 patients , fou r we re c
las s ified as
ac
u te withallothe rs c
las s ified as e ithe rpe rm ane nt hou s ingorc
hronicc
are .
T he are ais staffe d withat le ast one R N pers hift e xc
e pt forone 11-7s hift. D u ringthis s hift, the re is
aR N in the bu ild ingbu t not as s igne d to the infirm ary. A s are s u lt, aLic
e ns e d P rac
tic
alN u rse (LP N )
is d ire c
tingthe c
are in the infirm ary whic
h, ac
c
ord ingto the Illinois N u rs e P rac
tic
e A c
t, is be yond
the s c
ope ofprac
tic
e foraLP N . A d d itionally, the fac
ility is u s ingC ertified N u rs ing
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 25
A s s istants (C N A s )on the 7-3and 3-11s hifts and s oon on the 11-7s hift. U s e ofthe C N A s is going
we lland qu ite be ne fic
ialin provid ingc
are .
Ins pe c
ate d alarge , we ll-lighte d , re as onably we llm aintaine d and c
le an u nit.
T he infirm ary is c
onfigu re d in are c
tangle , two longhalls and two s hort halls at e ac
he nd , withthe
patient room s alongthe ou te rpe rim e te rofthe re c
tangle . A s are s u lt, the re are nu m e rou s wind ows
provid ingnatu rallight.
P atient be d s are in re as onably good s hape . R e c
e ntly, u s e d trad itional-s tyle hos pitalbe d s had be e n
pu rc
has e d from the loc
alhos pital, and m ore are goingto be pu rc
has e d whic
h willu pgrad e the
m ajority ofthe be d s . E ac
hofthe be d s has am attre s s withan im pe rviou s c
oatingc
ond u c
ive for
c
le aning/sanitizingwhe n ne e d e d , bu t partic
u larly be twe e n patients .
A longone longand one s hort hallway, e ac
hofthe be d s has ac
allbu tton loc
ate d on the wallabove
the be d . T he c
allbu tton provide s avisu alind ic
atorou ts ide the patient room and on anu m be re d
pane lins id e the nu rs ings tation;howe ve r, the re is no au d ible ind ic
ator. Sinc
e the c
allbu ttons are
m ou nte d on the wall, d e pe nd ingon the patient
s c
ond ition, it c
ou ld be d iffic
u lt to im pos s ible for
the patient to ac
c
e s s the c
allbu tton.
A longthe othe rlonghallway, the re are no patient c
allbu ttons , and s ix ofthe room s have no line of-s ight to the nu rs ings tation. B e lls have be e n provide d for the patient to m anu ally ring. W he n
m e d ic
alpe rs onne lare in the nu rs ings tation are a, d oors to e ac
hhallway are c
los e d . A s are s u lt, if
pe rs onne lwe re in the nu rs ings tation oroc
c
u pied in apatient room , it is d ou btfu lthe be llc
ou ld be
he ard . A d d itionally, ifthe patient be c
am e inc
apac
itate d , he c
ou ld not ringthe be ll.
E ac
hbe d had abe d s id e table bu t the re are no ove r-the -be d table s . A s are s u lt, patients e ithe re at
hold ingthe ir food tray on the ir laps orby plac
ingthe tray on the irbe d . Forpatients who c
annot
ge t ou t ofbe d , plac
e m e nt ofthe food tray c
ond u c
ive to e atingis d iffic
u lt.
T he re is one ne gative -air pre s s u re re s piratory isolation room loc
ate d in the infirm ary. N e gative
airflow is only c
he c
ke d e ve ry 30d ays re gard le s s ifare s piratory isolation patient is oc
c
u pyingthe
room .
R e s pons ibilities ofR N s workingthe infirm ary are :
1. Su pe rvision ofalls taffand patients
2. IV the rapy and m e d ic
ations
3. A s s e s s m e nts
4. P hle botom y
5. D re s s ingc
hange s
6. C harting
R e s pons ibilities ofLP N s workingthe infirm ary are :
1. Su pe rvision ofC N A s
2. A d m inistration oforaland topic
alm e d ic
ations
3. D re s s ingc
hange s
4. C harting
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 26
5. A s s e s s m e nts
R e s pons ibilities ofC N A s workingthe infirm ary are :
1. C olle c
tingand re c
ord ingvitals igns
2. B athingpatients
3. Fe e d ingpatients
4. C hangingbe d line ns
5. Fole y c
athe te rc
are
6. M e as u ringand re c
ord ingintake and ou tpu t
Ins pe c
tion ofinfirm ary line ns re ve ale d the following:
1. T hre ad bare s he e ts
2. T orn/fraye d s he e ts
3. T orn/fraye d towe ls and was hc
loths
4. Ins u ffic
ient nu m be rofpillows
5. Ins u ffic
ient nu m be rofblanke ts
6. Staine d s he e ts , towe ls and was hc
loths
In ins pe c
tingthe infirm ary, the re s e e m e d to be an abs e nc
e of ne e d e d patient c
are e qu ipm e nt as
follows :
1. IV pu m ps
2. T u be Fe e d ingpu m ps
3. H oye rlift
4. M axi-Lift B e d s lid e
5. Ge riC hairs (c
u rre nt c
hairs ne e d to be re c
ove re d in ord e rto ad e qu ate ly c
le an/sanitize
6. B e d alarm s
From as afe ty pe rs pe c
tive , the re was no s e c
u rity pre s e nc
e within the infirm ary e ve n thou ghall
sec
u rity c
las s ific
ations , m axim u m -m e d iu m -m inim u m , are hou s e d within this one are a. T he re is a
m anne d s e c
u rity s tation on the s e c
ond floor, bu t the offic
e ris e nc
los e d in aroom whic
his d own a
longhallway and s e parate d by ad oorfrom the nu rs ings tation and patient c
are are as . M e d ic
als taff
is not iss u e d ind ivid u alpanicalarm s orrad ios . Two rad ios are iss u e d to the infirm ary, howe ve r,
on the 7-3and 3-11s hifts ifm ore than two s taffis working. Ifam e d ic
als taffpe rs on was as s au lte d
in one of the bac
k patient c
are room s and had no rad io, it is d ou btfu lthe s e c
u rity s taff pe rs on
s tatione d 50 to 60 fe e t away be yond ac
los e d d oor and within an e nc
los e d room c
ou ld he ar any
c
ries forhe lp. A t the le as t, ad d itionalrad ios s hou ld be provide d and , optim ally, ind ivid u alpanic
alarm s . A d d itionally, while a s e c
u rity e s c
ort is re qu ire d d u ringm e d ic
ation ad m inistration in
d e s ignate d hou s ingu nits , no s u c
hesc
ort is provid e d in the infirm ary d e s pite alls e c
u rity le ve ls
be inghou s e d in this one are a.
N u rs ings taffwe re knowle d ge able c
onc
e rningthe patient popu lation, c
onc
e rningac
u te orc
hronic
c
are s tatu s , c
u rre nt ac
tivities /c
apabilities , he alth c
are /phys ic
al/soc
ial ne e d s and pe rs onalities .
W hile be ingable to e as ily artic
u late the above , nu rs ings taff c
hartingwas ve ry ge ne ricand
u ninform ative . It is u nd e rs tand able withge ne rally long-term , longs tay s kille d nu rs inghom e type s
ofpatients to fallinto the habit that the re is nothingne w to s ay abou t the patient. Ifs taffwou ld pu t
into word s what the y ve rbalize d abou t patients , c
hartingwou ld be
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 27
e nhanc
e d and c
ons id e rably m ore d e s c
riptive and inform ative c
onc
e rningthe patient
s c
u rre nt
c
ond ition.
W e fou nd the provide rs d oc
u m e ntation to be s im ilarly lac
king. In m any c
as e s , patients we re not
s e e n tim e ly pe rpolic
y, norwe re e valu ations c
om pre he ns ive . R are ly we re phys ic
ale xam inations
orm e d ic
ald e c
ision m akingd oc
u m e nte d , and m anage m e nt was qu e s tionable in s e ve ralc
as e s .
E xam ple s are d e s c
ribe d be low.
Patient #1
T his patient is a68-ye ar-old m ale who was ad m itte d on 12/27/2013. H e is pe rm ane ntly as s igne d
to the infirm ary followingate rm inald iagnos is of c
anc
e r ofthe brain (glioblas tom a)as we llas
c
hronic lym phoc
ytic le u ke m ia, hype rte ns ion, pu lm onary hype rte ns ion and c
hronic atrial
fibrillation. H e re c
e ive d a s e ries of rad iation tre atm e nts in Ju ne 2013. H e s igne d a D o N ot
R esu sc
itate (D N R )ord e r 12/27. P e r ID O C polic
y, the re c
ord ingof vitals igns and c
hartingis
re qu ire d we e kly forapatient ofthis s tatu s . A re view ofc
hartingind ic
ate d , ge ne rally, d aily nu rs ing
note s , and at le as t we e kly phys ic
ian note s . A phys ic
ian ad m iss ion note c
ou ld not be loc
ate d . T he
ad m iss ion R N note was d ate d 12/27.
Patient #2
T his patient was ad m itte d 10/21/2012. In Janu ary 2012, this patient was d iagnos e d with lu ng
c
anc
e r whic
h had m e tas tas ize d to the brain. H e re c
e ive d both c
he m o and rad iation the rapy. A t
pre s e nt he is be d rid d e n and atotalc
are patient. P hys ic
ian and nu rs ingnote s we re d oc
u m e nte d at a
m inim u m we e kly.
Patient #3
T his patient was ad m itte d 2/12/2009, and has along-term d iagnos is ofP arkins on
s d ise as e . P atient
has afe e d ingtu be , Fole y c
athe te r and a2 c
m x 1c
m d ec
u bitu s on the c
oc
c
yx. T he patient is
c
las s ified as c
hronicc
are and , e ve n thou gh only we e kly phys ic
ian and nu rs ing note s are
re qu ire d , c
hartingis m ore fre qu e nt.
Patient #4
T his patient was ad m itte d 2/25/2014. C las s ified as ac
u te c
are d u e to influ e nz ainfe c
tion. T he re
we re appropriate phys ic
ian and R N ad m iss ion note s and c
olle c
tion and re c
ord ingof vitals igns ,
he ight and we ight. C hartingand the re c
ord ingofvitals igns was pe rform e d at am inim u m d aily.
Patient #5
T his patient is a46-ye ar-old m an with history of as thm a, s e izu re s and m e ntalillne s s who was
ad m itte d ac
u te ly to the infirm ary on 2/19/14withhyponatre m ia(s od iu m 122m g/d L). T he re was
an appropriate R N ad m iss ion note and c
olle c
tion and re c
ord ingofvitals igns , he ight and we ight.
A d d itionalc
harting, inc
lu d ingvitals igns , oc
c
u rre d at am inim u m d aily. T he phys ician
s ad m iss ion
note was fairly thorou ghe xc
e pt the re was no ne u rologice xam , argu ably the m os t im portant s ys te m
to e xam ine in apatient withlow s od iu m .
T he re is anothe rnote by aphys ic
ian on 2/21, bu t it is only are view ofthe labs ;the patient was not
s e e n. A t this tim e , the s od iu m was u p to 128 m g/d L and s alt table ts we re ad d e d . T he re was no
work-u pto d ete rm ine the c
au s e ofthe patient
s low s od iu m .
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 28
O n 2/25, the re is aphys ician note d e s c

ribingthe patient as u nru ly and d isru ptive . H e was not
e xam ine d , pre s u m ably d u e to his be havior. It was note d that the patient has be e n hou s e d in aroom
whe re he has fre e ac
c
e s s to wate rd e s pite his ord e rforflu id re s tric
tion.
Opinion:T his patient has not be e n s e e n by the phys ic
ian ac
c
ord ingto polic
y and his low s od iu m
has not be e n prope rly inve s tigate d . Salt table ts are not appropriate tre atm e nt forthe m os t c
om m on
c
au s e oflow s od iu m in ou tpatients (SIA D H ).
Patient #6
T his patient was ad m itte d 2/17/2012 and c
las s ified as c
hronic c
are d u e to e nd -s tage
C O P D /A s thm a. D N R s igne d 5/13/2011. C u rre ntly ad m itte d to ac
om m u nity hos pital. A re view of
the re c
ord ind ic
ate d m ore than we e kly nu rs ingnote s and vitals ign d oc
u m e ntation withphys ic
ian
note s be ing, at am inim u m , we e kly.
Patient #7
T his patient was ad m itte d 12/24/2013. C las s ified as ac
u te c
are d u e to u nc
ontrolle d d iabe te s . T he
patient c
od e d 12/16/2013in his hou s ingu nit. E M S was c
alle d and d u ringtrans port to ac
om m u nity
hos pital, the patient arre s te d in the am bu lanc
e . T he patient was re vive d , s tabilize d and trans porte d
to U IC whe re he re m aine d u ntil12/24, whe n he was re tu rne d to the ins titu tion. T he re is aR N
ad m iss ion note bu t no phys ic
ian ad m iss ion note. V itals igns and nu rs ingnote s are re c
ord e d at a
m inim u m d aily.
Patient #8
T his pate nt is a25-ye ar-old m an ad m itte d to the infirm ary c
hronic
ally on 1/28/14afte rfrac
tu ring
his jaw and havingit wire d s hu t. T he re is nu rs ingad m iss ion note, bu t it was not tim e d . T he re was
abriefnote by the M e d ic
alD ire c
toron 1/31, bu t itwas the nu rs e prac
titione rwho d id the ad m iss ion
note the followingd ay. T he nu rs e prac
titione r s aw him again awe e k late r. O n 2/11, the M e d ic
al
D ire c
tornoted as ix-pou nd we ight los s s inc
e ad m iss ion;this was the las t provide rnote in the c
hart
as of the d ate of ou r visit 10 d ays he nc
e . T he re we re s hift nu rs ingnote s and d aily vitals igns
d oc
u m e nte d . W ire c
u tte rs are im m e d iate ly available in the nu rs ings tation.
Opinion:T his patient has not be e n s e e n tim e ly d u ringhis infirm ary ad m iss ion. H e s hou ld be
e valu ate d forwe ight los s .
Patient #9
T his patient is a52-ye ar-old m an withno known m e d ic
alhistory who was ad m itte d to the infirm ary
on 2/13/14forac
u te c
are followingan e pisod e ofu nre s pons ive ne s s and s e izu re s in Janu ary ofthis
ye ar. H e was fou nd to have s e ps is from s tre ptoc
oc
c
alm e ningitis and ac
ave rnou s s inu s throm bos is.
T he re are appropriate ly d oc
u m e nte d phys ic
ian and nu rs ingad m iss ion note s . T he re are d aily vital
s igns and s hift nu rs ingnote s ;howe ve r, he has not be e n s e e n by the phys ic
ian pe rpolic
y while in
the infirm ary. T he re we re only two phys ic
ian visits d oc
hart as ofthe tim e ofou r
visit on 2/27.
Opinion:T his patient has not be e n s e e n by aphys ic
ian pe rpolic
y. C ons id e ringthe s e ve rity ofhis
illne s s , this is partic
u larly proble m atic
.
Patient #10
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 30
29
T his patient was ad m itte d 8/30/2012d u e to re pe ate d falling, hallu c

inations and T IA s . T he patient
was pe rm ane ntly as s igne d to the infirm ary. O n 2/22/2014, while goingto the bathroom , he fe ll,
frac
tu ring his le ft d istal fe m u r. H e was trans porte d to a c
om m u nity hos pital whe re an
intram e d u llary fixation was pe rform e d . T he patient was retu rne d to the fac
ility whe re he re m ains
in the infirm ary. T he re was athorou gh, we ll-writte n R N ad m iss ion note ;howe ve r, it was not
s igne d .
Patient #11
T his is a77-ye ar-old m an with c
ognitive im pairm e nt who has be e n c
hronic
ally hou s e d in the
infirm ary s inc
e at le as t Janu ary 2013, whic
h is whe n his progre s s note s be gin. H is proble m list
was las t u pd ate d in M arc
hof2012and lists only B P H and ps orias is.
In A pril2013, he was s e e n in c
ons u ltation by U IC ne u rology forhis m e m ory los s . T he y re qu e s te d
labs , C T ofthe he ad and an E E G, as partialc
om ple x s e izu re s we re in the d iffe re ntiald iagnos is.
T he E E G was not approve d and the C T (d one two m onths late r)s howe d only s m allve s s e lisc
he m ic
c
hange s . In Ju ly 2013, ne u rology follow-u pwas d e nied . T he d e c
ision was that the patient probably
has d e m e ntiaand tre atm e nt withA ric
e pt s hou ld be c
ons ide re d . It was ne ve rs tarte d .
H e is on the m e ntalhe althc
as e load and pre s c
ribe d s e ve ralps yc
hotropicm e d ic
ations , inc
lu d ing
R ispe rd al, whic
h is re lative ly c
ontraind ic
ate d in e ld e rly d e m e ntiapatients and has ablac
k box
warningforthis s e ttingd u e to inc
re as e d risk ofs troke and d e ath. H e is re pe ate d ly d e s c
ribe d as
friend ly, c
alm and c
oope rative in the re c
ord , s o it is not c
le arwhy an antips yc
hoticm e d ic
ation is
ne c
e s s ary;the risks appe ar to ou twe igh the be ne fits . H e is d e s c
ribe d as d e lu s ionalwith s om e
au d itory hallu c
inations , bu t the s e d o not appe arto be d istre s s ingto him and are not abou t harm ing
s e lforothe rs .
H e was s e e n we e kly throu ghM ay;the note s appe are d ad e qu ate . H e was not s e e n by aprovide rat
allin Ju ne . In Ju ly the re we re two note s ;the firs t appe ars to be ac
hart re view, as the re we re no
vitals , no e xam and no s u bje c
tive inform ation. It is not c
le ar that the provide r ac
tu ally s aw the
patient. T he s e c
ond note was foras kin ras h.
H e was s e e n onc
e in A u gu s t by the M e d ic
alD ire c
tor. A gain, the re was no phys ic
ale xam or
s u bje c
tive inform ation. T he re is no c
onvinc
inge vid e nc
e that the re was inte rac
tion be twe e n the
d oc
torand the patient.
T he M e d ic
alD ire c
tors aw him we e kly in Se pte m be r, bu t no note s c
ontain aphys ic
ale xam , only
u pin d ay room ,u pabou t,N A D ,s u gge s tingthat he was m e re ly obs e rve d from afar.
In O c
tobe r, the M e d ic
alD ire c
tor s aw him for bac
k pain with ins piration. T he re was no e xam ,
as s e s s m e nt orplan. She ord e re d ac
he s t x-ray, whic
hwas d one the ne xt d ay and re porte d as norm al.
W he n s he s aw him again five d ays late r, the re was no m e ntion ofthe bac
k pain.
O n 11/17/13, the R N note d ale ft fac

iald roop. T he M e d ic
alD ire c
tors aw the patient the ne xt d ay
and note d , R e porte d u nable to ke e ple ft e ye c
los e d at noc
.T he re was no e xam , no as s e s s m e nt or
d iagnos is. She ord e re d the le ft e ye to be tape d s hu t. T he followingd ay, s he note d ale ft fac
iald roop
and d iagnos e d B e ll
s pals y. She ord ere d artific
ialte ars and c
ontinu e tapingthe e ye s hu t. N o worku porothe rtre atm e nt was initiate d .
H e was s e e n onc
e m ore in N ove m be r, twic
e in D e c
e m be r, we e kly in Janu ary, and onc
e in Fe bru ary
as ofthe d ate ofou rvisit (2/26).
R e view ofhis pe rm ane nt re c
ord (whic
his als o ke pt in the infirm ary)re ve ale d that in Ju ly 2012
the patient had ac
olonos c
opy s howingtwo ad e nom atou s polyps , one ofwhic
hs howe d high-grad e
d ys plas iaon pathology. T he re has be e n no follow-u pc
olonos c
opy as ofthe d ate ofou rvisit.
Opinion:T his patient has not be e n s e e n ac
c
ord ingto polic
y while in the infirm ary. T he note s are
inad e qu ate ;m os t lac
k s u bje c
tive orobje c
tive inform ation and rare ly artic
u late m e d ic
ald e c
isionm aking. T his patient s hou ld have be e n tre ate d withs teroids forhis B e ll
s pals y, in ac
c
ord anc
e with
c
u rre ntly pu blishe d gu ide line s . A s e riou s , pre c
anc
e rou s c
ond ition has be e n ove rlooke d in this c
as e .
T his c
as e was brou ght to the atte ntion ofthe M e d ic
alD ire c
torforfollow-u p.
Patient #12
T his is a45-ye ar-old with hype rte ns ion, s e ve re tre m ors and as e izu re d isord e r who was in the
infirm ary from at le as t A u gu s t u ntilN ove m be rof2013. T he re we re two phys ic
ian note s in A u gu s t,
rou ghly we e kly in Se pte m be r, two visits in O c
tobe rand one in N ove m be r. N one c
ontain aphys ic
al
e xam that re fle c
ts that the provid e r laid ahand on the patient. A lls im ply d e s c
ribe obs e rvations ;
tre m or,u pto e at in d ay room ,in be d ,e tc
.
Opinion:T his patient was not s e e n in ac
c
ord anc
e withpolicy, nord o the note s re fle c
t that he was
e xam ine d in the las t s ix m onths .
Infirmary Care Issues

1. LP N s are workingou ts ide the s c
ope ofprac
tic
e.
2. P atients are not s e e n ac
c
ord ingto polic
y by provid e rs . R are ly is the re e vid e nc
e that patients
are phys ic
ally e xam ine d .
3. O ne 11-7s hift has no R N as s igne d to the infirm ary and aLP N is d ire c
tingthe c
are . A gain,
this plac
e s the LP N in the pos ition ofworkingou ts ide the s c
ope ofprac
tic
e be c
au s e the
LP N m ay ne e d to e valu ate apatient c
om plaint, e xam ine the patient and bas e d on the
find ings ofthe e xam ination and patient s ym ptom s , form an as s e s s m e nt, and bas e d on the
as s e s s m e nt, d e ve lop and im ple m e nt a plan of tre atm e nt. A ll of this is be yond the
ed u c
ationalpre paration and s c
ope ofprac
tic
e foraLP N .
4. Stale , non-d e s c
riptive and u ninform ative c
harting.
5. Inc
om ple te c
hartingwith d ate s /tim e s , vital s igns , s ignatu re s m iss ingand the re qu ire d
SO A P form at not always u s e d .
6. C allbu ttons pos itione d whe re it c
ou ld be d iffic
u lt to im pos s ible forthe patient to ac
c
ess.
7. N o c
allbu ttons in the patient room s alongone longhallway and no d ire c
t line -of-s ight to
the nu rs ings tation in s ix ofthe room s .
8. N o s e c
u rity pre s e nc
e in the infirm ary d e s pite alls e c
u rity c
las s ific
ations be ingpre s e nt.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 32
31
9. N ot e nou ghrad ios and no panicalarm s available forstaff.

10. Ins u ffic
ient e qu ipm e nt.
11. Ins u ffic
ient am ou nt ofnon-thre ad bare , non-torn/fraye d ornon-s taine d line ns and blanke ts .
12. Ins u ffic
ient nu m be rofpillows .
Infection Control
A t pre s e nt, the re is no nam e d infe c
tion c
ontrolnu rs e . T he two nu rs ings u pe rvisors are re s pons ible
forc
om plianc
e withID O C polic
yc
onc
e rningc
om m u nic
able d ise as e s , blood borne pathoge ns and
c
om plianc
e withIllinois D e partm e nt ofP u blicH e althre portingre qu ire m e nts .
T he fac
ility has ac
ontrac
t withalarge nationwid e m e d ic
om pany whic
hc
om e s
on s ite two tim e s pe rm onthto hau laway m e d ic
alwas te . T he re we re no re porte d iss u e s withthis
s e rvic
e.
Ins pe c
tion ofthe infirm ary, s ic
kc
ald e partm e nt and X -hou s e and e m e rge ncy
re s pons e bags ve rified the pre s e nc
e ofpe rs onalprote c
tu re proofc
ontaine rs
forthe d ispos alofs harps are in u s e in allm e d ic
alare as and are appropriate ly plac
e d in the m e d ic
al
was te c
Inm ate s as s igne d as porters in the infirm ary and who pe rform janitoriald u ties m ay orm ay not
have re c
e ive d any trainingas to appropriate c
le aningand s anitation m e thod s . N u rs ings u pe rvisors
have not ad d re s s e d the iss u e withthe porters .
R e portable ST Is are pic
ke d -u pand re porte d by U IC .
Dental Program
Executive Summary
O n Ju ly 15 and 16, 2014, a c
om pre he ns ive re view of the d e ntal program at D ixon C C was
c
om ple te d . Five are as ofthe program we re ad d re s s e d :1)inm ate s ac
c
are ;2)
the qu ality ofc
are ;3)the qu ality and qu antity ofthe provide rs ;4)the ad e qu ac
y ofthe fac
ility and
e qu ipm e nt d e vote d to d e ntalc
are ;and 5)the ove ralld e ntalprogram m anage m e nt. T he following
obs e rvations and find ings are provide d .
T he c
linicits e lfis rathe rlarge and s pac
iou s and we lle qu ippe d . It is athre e -c
hairc
linic
, bu t one of
the c
hairs is not fu nc
tioning. N o plans forre pairare in plac
e . A lthou ghthe s taffingle ve lforthe
d e ntists is ad e qu ate , the re is no hygienist on the d entals taff. A s s u c
h, hygiene c
are is ne arly none xiste nt. T his is as e riou s om iss ion and ahygienist s hou ld be hire d as s oon as pos s ible .
A m ajorare aofc
onc
e rn re late s to c
om pre he ns ive c
are . C om pre he ns ive c
are was provide d withou t
ac
om pre he ns ive intra and e xtra-oral e xam ination and we ll d e ve lope d tre atm e nt plan. N o
e xam ination ofs oft tiss u e s norpe riod ontalas s e s s m e nt was part ofthe tre atm e nt proc
ess.
H ygiene c
are and prophylaxis we re ne ve r provid e d and oral hygiene ins tru c
tions we re ne ve r
d oc
u m e nte d . B ite wingorpe riapic
alrad iographs we re ne ve rtake n to d iagnos e c
aries . R e s torations
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 33
we re provide d from the inform ation on apane lips e rad iograph. N one of the re c
ord s re viewe d
d oc
u m e nte d the tim e ofthe appointm e nt.
A s im ilar are a of c
onc
e rn is d e ntal e xtrac
e e d from a
d oc
the re c
ord s re viewe d was ad iagnos is orre as on forthe e xtrac
tion inc
lu d e d . A larm ingly, in none of
the re c
ord s re viewe d was ac
ons e nt fortre atm e nt form available . T his is as e riou s om iss ion and
ne e d s to be c
orre c
ons tru c
e ofc
are d e live ry inc
lu d e d in
the c
om pre he ns ive c
are proc
e s s . A re view of s e ve ralre c
ord s re ve ale d that allpartiald e ntu re s
proc
e e d e d withou t ac
om pre he ns ive e xam ination and tre atm e nt plan. P e riod ontalas s e s s m e nt and
tre atm e nt was s e ld om provide d . O ralhygiene ins tru c
lu d e d . It was alm os t
im pos s ible to d e m ons trate that allfillings and e xtrac
tions we re c
om ple te d prior to im pre s s ions .
P e riod ontalhe althwas ne ve rd oc
u m e nte d .
A t D ixon C C , d e ntals ic
kc
allis ac
c
e s s e d throu ghad aily s ic
kc
alls ign u p throu ghthe m e d ic
al
d e partm e nt and viathe inm ate re qu e s t form . T he re was no s ys te m in plac
are
ne e d s (pain and /ors we lling)from the re qu e s t form . Inm ate s withu rge nt c
are c
om plaints from the
re qu e s t form ofte n took fou rorfive d ays to be s e e n by the d e ntist fore valu ation. T he s e inm ate s
s hou ld be s e e n within 24-48hou rs from the d ate ofthe re qu e s t form .
In none ofthe re c
ord s re viewe d was the SO A P form at be ingu s e d . T re atm e nt was provid e d with
little inform ation or d etailpre c
e d ingit. R e c
ord entries d id not inc
lu d e c
linic
alobs e rvations or
d iagnos is to ju s tify tre atm e nt.
A we ll d e ve lope d P olic
y and P roc
e d u ral M anu al ins u re s that a d e ntal program ad d re s s e s all
ontinu ity. T he P olic
y and P roc
e d u re s m anu alat D ixon C C only
paraphras e s the A d m inistrative D ire c
tive s . It inc
lu d e d nothings pe c
ificfor D ixon C C and the
ru nningof the d e ntal program . T he d e ntal d ire c
tor kne w little of its e xiste nc
e and had ne ve r
re viewe d it.
T he D ixon C C Inm ate O rientation M anu alonly m e ntions d e ntalin re lation to c
o-pays . N o m e ntion
is m ad e on ac
c
e s s to c
are.
M e d ic
alc
au tions and c
ord and re d
flagge d to bringthe m to the im m e d iate atte ntion ofthe provide r. T he d e ntalre c
ord is m aintaine d
in the d e ntalc
linics e parate from the m e d ic
alre c
ord . Id e ntific
ation on the d e ntalre c
ord ofinm ate s
on antic
oagu lant the rapy was ve ry inc
ons iste nt and s e ld om re d flagge d .
B lood pre s s u re s s hou ld , at the le as t, be take n on patients withahistory of hype rte ns ion. W he n
as ke d , the c
linic
ians ind ic
T he s te rilization flow from d irty to ste rile was im proper. T he re was no biohaz ard labe lpos te d in
the s terilization are a. Safe ty glas s e s we re not always worn by patients . A rad iation haz ard warning
s ign was not pos te d in the x-ray are a.
T he c
ontinu ingqu ality im prove m e nt proc
e s s was inad e qu ate ly u tilize d . A s tu d y was in proc
ess
bu t s e e m e d rathe rins ignific
ant. C Q I stu d ies s hou ld be d e ve lope d to ad d re s s program d e fic
ienc
ies
note d in the bod y ofthis re port.

D ixon C C has ad e ntals taffofone fu ll-tim e d e ntist, one 14-hou rpart-tim e d e ntist and two fu lltim e as s istants . T he re is no hygienist at D ixon C C . T his is as e riou s om iss ion. T o e xpe c
t the
d e ntists to provide hygiene and pe riod ontalc
are to apopu lation the s ize ofD ixon C C is u nre alistic
and u nobtainable . It is als o apooru s e ofad e ntist
s tim e and re s ou rc
e s . A d e ntalhygienist s hou ld
im m e d iate ly be m ad e part ofthe d e ntals taffat D ixon C C .
C P R trainingis c
e s s ary lic
forthe d e ntists .
Recommendations:
1. T hat ad e ntalhygienist im m e d iate ly be m ad e part ofthe d e ntals taffat D ixon C C .

T he c
linicc
ons ists ofthre e c
hairs and u nits , one fore ac
hd e ntist and athird fore ithe rofthe two
d e ntists . T wo ofthe d e ntalu nits are two ye ars old and in ve ry good re pair. T he third c
hairis ve ry
old , worn and d oe s not work at all. N o plans to repairthis c
hairare in plac
e . T he re is apanore x
u nit in the he alths e rvic
e s x-ray d e partm e nt in ad e d ic
ate d room . It is old bu t fu nc
tions ad e qu ate ly.
T he x-ray u nit in the c
linicis in good re pairand works we ll. T he au toc
lave is old e rbu t fu nc
tions
we ll. T he c
om pre s s or is in the bas e m e nt and works we ll. T he ins tru m e ntation is ad e qu ate in
qu antity and qu ality. T he d e ntist e xpre s s e d no c
om plaints . T he hand piec
e s are old e r bu t we ll
m aintaine d and re paire d whe n ne c
e s s ary. T he c
abine try is rathe r old and s howingwe ar and
c
orros ion and s tainingon work s u rfac
e s , bu t fu nc
tionally alright. T his d oe s m ake d isinfe c
tion of
s u rfac
e s m ore d iffic
u lt. T he u ltras onicworks we ll.
T he c
linicits e lf c
ons ists of thre e c
hairs in thre e s e parate and ad e qu ate s pac
arou nd e ac
hu nit is ac
c
e ptable . P rovid e rand as s istant have ad e qu ate room to work and none ofthe
c
hairs inte rfe re withe ac
hothe r. T he re was as e parate s terilization are aofad e qu ate s ize and s u rfac
e
works pac
e . T he s taffoffic
e is large withas ingle d e s k. T he d e ntalre c
ord s are m aintaine d in this
room . It als o hou s e s the d e ntallaboratory withits e qu ipm e nt and works pac
e . T he re is ad e qu ate
room forall.
T he c
linicis ad e qu ate in s ize and fu nc
tion to m e e t the ne e d s ofthe inm ate popu lation at D ixon
CC.
Recommendations:
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 34
1. R e pairorre plac
e the c
hairand u nit that is not working.

I obs e rve d the s anitation and s te rilization te c
hniqu e s and proc
e d isinfe c
tion was
tants we re be ing
u s e d . P rote c
tive c
ove rs we re u tilize d on s om e ofthe s u rfac
es.
abine ts re ve ale d that the y we re prope rly bagge d and
s te rilize d . A llhand piec
e d u re its e lf was flawe d . Flow s hou ld go from d irty to s te rile in a line ar
fas hion. T he u ltras onicwas on the oppos ite s ide ofthe au toc
lave from the s ink. It s hou ld flow from
u ltras onicto s ink to work are ato au toc
lave withou t c
ros s ingits path.
tion is always ne c
e s s ary, forpatient and provid e r. I als o obs e rve d that
no warnings ign was pos te d whe re x-rays we re be ingtake n to warn ofrad iation haz ard s , e s pe c
ially
to pre gnant fe m ale s .
T he c
linicwas , allin all, c
le an, ne at and ord e rly.

I looke d bac
k thre e ye ars and fou nd the s te rilization logs to be in plac
au toc
lavingwas ac
c
u m e nte d . T he y u tilize the M axite s t s ys te m throu gh
H e nry Sc
he in. A s ingle ne gative re s u lt was d oc
u m e nte d , bu t c
orre c
te d im m e d iate ly withare te st,
whic
hwas ne gative . I d id obs e rve that no biohaz ard warnings ign was pos te d in the s te rilization
are a.
Recommendations:
1. T hat the s te rilization flow to the au toc
lave be c
orre c
te d as s u gge s te d .
4. A warnings ign be poste d in the x-ray are ato warn pre gnant fe m ale s ofrad iation haz ard s .
Comprehensive Care
tive tre atm e nt c
las s ified as C ate gory 3patients . O ne
ofthe m os t bas icand e s s e ntials tand ard s ofc
are proc
e e d from a
thorou gh, we lld oc
u m e nte d intraand e xtra-orale xam ination and awe lld e ve lope d tre atm e nt plan,
to inc
lu d e allne c
e s s ary d iagnos ticx-rays . A re view of10re c
ord s re ve ale d that no c
om pre he ns ive
e xam ination was e ve rperform e d and no tre atm e nt plans d e ve lope d . N o e xam ination ofs oft tiss u e s
or pe riod ontalas s e s s m e nt was part ofthe tre atm e nt proc
e s s . H ygiene c
are and prophylaxis was
ne ve rprovide d and oralhygiene ins tru c
tions we re ne ve rd oc
u m e nte d . B ite wingorperiapic
alx-rays
we re ne ve rtake n to d iagnos e c
aries . R e storations we re provide d
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 35
from the inform ation from the panore x rad iograph. T his rad iographis not d iagnos ticforc
aries . A
pe riod ontalas s e s s m e nt was not d one in any ofthe re c
ord s . N one ofthe re c
ord e ntries we re tim e
d oc
u m e nte d .
Recommendations:
are be provid e d only from awe lld e ve lope d and d oc
u m e nte d
tre atm e nt plan.
2. T he tre atm e nt plan be d e ve lope d from athorou gh, we lld oc
tiss u e s .
3. In allc
as e s , that appropriate bite wingorpe ri-apic
aries .
4. H ygiene c
ess.
5. T hat c
e s and d e ntal
prophylaxis.
u m e nte d .
7. T hat allre c
ord e ntries inc
lu d e d ate and tim e .
Dental Screening
W e re viewe d 10 inm ate d e ntalre c
e ption c
e nte rs within the
pas t 60d ays to d ete rm ine if:1)s c
e ption c
e nte rand 2)apanoram ic
x-ray was take n. A lthou ghD ixon C C is not are c
e ption and c
las s ific
ation c
e nte r, I re viewe d the s e
re c
ord s to ins u re the re c
e ption and c
las s ific
ation polic
tive
04.03.102, s e c
tion F. 2, are be ingm e t forthe ID O C .
om plianc
e.
Extractions
O ne ofthe prim ary te nets in d e ntistry is that alld e ntaltre atm e nt proc
e ed s from awe lld oc
u m e nte d
d iagnos is. In none ofthe 10re c
ord s e xam ine d was ad iagnos is orre ason fore xtrac
tion inc
lu d e d as
part ofthe d e ntalre c
ord e ntry. In none ofthe re c
ons e nt form available . W he n
as ke d , I was told that it was ju s t not apart ofthe tre atm e nt proc
e s s fors u rgery at D ixon C C . T his
is as eriou s om iss ion and am ajor violation of awe lle s tablishe d s tand ard of c
are. It le ave s the
ins titu tion u nne c
e s s arily e xpos e d to pote ntiallitigation.
Recommendations:
tion be inc
be s t ac
c
ially fors ic
kc
alle ntries .
d e ntal re c
ord inc
e as to why that
tre atm e nt was provide d . N e ithe rthe patient
sc
om plaint northe d e ntist
s find ings.
2. T hat ac
ons e nt form be d e ve lope d and s igne d by the patient and the d e ntist. T hat the
proc
e d u re and any pote ntialc
om plic
ations be we lle xplaine d to the patient.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 36
s s hou ld proc
ord e d on
ad d re s s e d firs t. W e re viewe d d e ntalre c
ord s of five patients havingre c
e ive d c
om ple te d partial
d e ntu re s . In only two ofthe five re c
ord s re viewe d on patients re c
e ivingre m ovable partiald e ntu re s
we re oralhygiene ins tru c
tions provid e d . P e riod ontalas s e s s m e nt was not provide d in any ofthe
re c
ord s . In two of the five re c
ord s aprophylaxis and /or as c
alingd e brid e m e nt was provide d .
B ec
au s e the re is no c
om pre he ns ive e xam ination orany tre atm e nt plans d e ve lope d and d oc
u m e nte d
in any ofthe re c
ord s , it is alm os t im pos s ible to as c
e rtain ifallne c
e s s ary c
are , inc
lu d ingope rative
and /or orals u rge ry tre atm e nt, is c
ation ofre m ovable partiald e ntu re s . I
u s e d rad iographs and re c
ord e ntries to c
onc
lu d e that e xtrac
tions we re probably c
om ple te d .
Recommendations:
1. A c
inc
lu d ingbite wingand /or periapic
alrad iographs and pe riod ontalas s e s s m e nt, pre c
e d e all
c
are , inc
s.
e s s and that the
c
Dental Sick Call

W e re viewe d 10 d e ntals ic
kc
allc
harts to d ete rm ine ifthe y are ad e qu ate . Inm ate s ac
c
e s s d e ntal
s ic
kc
allthrou ghe ithe r as ic
kc
alls ign u p proc
e s s or viathe inm ate re qu e s t form . T he s ic
kc
all
s ign u ptake s plac
e in the he alths e rvic
e s u nit e ve ry m orning. T he y s ign u pone d ay and are s e e n
and e valu ate d the ne xt d ay by an R N . T he R N the n re fe rs the c
om plaint to the d e ntalprogram and
the inm ate is s c
he d u le d ford e ntalwithin fou rto five d ays . I am u ns u re why d aily s ic
kc
allis not
s e e n d ire c
tly by the d e ntal program . T he nu m be r is re lative ly s m all and c
ou ld e as ily be
ac
c
om plishe d . It wou ld ins u re that u rge nt c
are c
om plaints are ad d re s s e d in atim e ly m anne r.
R e qu e s t form s are re c
e ive d from the ins titu tion m ailand e valu ate d by the d e ntist and s c
he d u le d
foran e xam ination and e valu ation within fou rto five d ays . N o s ys te m was in plac
e to atte m pt to
s e e inm ate s withu rge nt c
are c
om plaints within 24to 48hou rs from the d ate ofthe re qu e s t form .
A gain, the nu m be ris s m alland the y c
ou ld e as ily be s c
he d u le d forthe ne xt workingd ay.
E m e rge nc
yc
all-ins from s taffare s e e n the s am e d ay.
In none ofthe re c
ord s was the SO A P form at be ingu s e d . A s s u c
h, little in the way ofad iagnos is
was available forany d e live re d c
are .
R ou tine c
are was not be ingprovide d at s ic
kc
allappointm e nts .
T he c
hiefc
om plaint, as we llas c
ou ld be d e te rm ine d , was be ingad d re s s e d at s ic
kc
all.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 37
Recommendations:
kc
s
c
hief c
om plaint is re c
d iagnos is pre c
2. D aily d e ntals ic
kc
alls hou ld be s e e n and e valu ate d by the d e ntist, rathe rthan throu ghthe
m e d ic
alprogram .
3. R e qu e s ts from inm ate s withu rge nt c
are c
om plaints s hou ld be s c
he d u le d forthe ne xt work
d ay from re c
e ipt ofthe re qu e s t form .
Treatment Provision
A rathe rwe ak triage s ys te m is in plac
e that prioritize s tre atm e nt ne e d s . A llinm ate re qu e s t form s
are e valu ate d from the d ay re c
e ive d by the d e ntalprogram and appointm e nts provid e d from this
e valu ation, u s u ally within fou rto five d ays . D aily s ic
kc
alls ign-u ps are s e e n by the R N
s by the
followingd ay, e valu ate d and provid e d pain m e d s if ne c
e s s ary. T he y are the n re fe rre d to d e ntal
fore valu ation. T he s e re fe rrals from the R N
s from d aily s ic
kc
alls ign-u ps are e valu ate d by the
d e ntalprogram by the followingd ay from re c
e ipt ofthe re fe rral, and s c
he d u lingis prioritize d .
T he y are s c
he d u le d ac
c
ord ingly or plac
e d on the tre atm e nt list. T he R N s have pain m e d ic
ation
protoc
ols available . N on-u rge nt c
are ne e d s are be ings e e n in atim e ly m anne r and the ir iss u e s
ad d re s s e d .
Inm ate s c
are viathe inm ate re qu e s t form , by s igningu pfors ic
kc
allwiththe R N ,
or, ifthe y fe e lthe y ne e d to be s e e n im m e d iate ly, by c
ontac
tingD ixon C C s taff, who willthe n
c
allthe d e ntalc
sc
om plaint. R e qu e s t form s are s e nt viathe ins titu tion m ail
and are e valu ate d the d ay the y are re c
e ive d in d e ntal, and s c
he d u le d ac
c
ord ingly, u s u ally thre e to
five d ays . Sic
kc
alls ign-u ps are s e e n by the followingd ay by aR N and e valu ate d and re fe rre d to
d e ntalby the ne xt d ay. T he y have pain m e d ic
ation protoc
ols available . A s s u c
h, it take s thre e to
five d ays ford e ntalto ad d re s s u rge nt c
are ne e d s . T he d e ntalc
linicre c
e ive s abou t thre e re qu e s t
form pe rd ay and only one in thre e orfou ris foru rge nt c
are , i.e ., pain, s we llingand toothac
he s .
T he s e inm ate s c
he d u le d the ne xt workd ay for d ire c
t e valu ation by the d e ntist.
A ls o, d e ntalc
ou ld s c
he d u le the s ic
kc
allpatients d ire c
tly, rathe rthan throu ghthe R N . T his wou ld
ins u re that u rge nt c
are ne e d s are ad d re s s e d in atim e ly m anne r, within one workingd ay.
Inm ate s who s u bm it re qu e s t form s for rou tine c
are are e valu ate d in the d e ntalc
linicwithin one
we e k and plac
e d s e qu e ntially on awaitinglist forthis c
are . T he waitinglist is approxim ate ly two
m onths longat this tim e . T he s ys te m is fairand e qu itable .
Recommendations:
1. T hat e fforts be m ad e to s e e u rge nt c
are c
om plaints viathe re qu e s t form in am ore tim e ly
m anne r. T he y c
he d u le d forthe ne xt d ay. Sic
kc
alls ign-u ps are s e e n the
followingd ay by R N s who have pain m e d ic
ation protoc
ols available . D e ntals ic
kc
alls ignu ps s hou ld be s c
he d u le d d ire c
tly by d e ntalfor the followingd ay, rathe r than by the R N
who the n re fe rs the m to d e ntal.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 38
T he D ixon C C O rientation M anu alonly m e ntions d e ntalin re lation to c
o-pays . It d e s c
ribe s m e d ic
al
s ic
kc
allproc
e d u re s , bu t no m e ntion is m ad e ofd e ntals ic
kc
all.
Recommendations:
1. A m e nd the orientation m anu alto inc
lu d e d e ntals ic
kc
allproc
e d u re s and ins tru c
tions on how
to ac
c
e s s rou tine , u rge nt and e m e rge nc
yc
are .

T he P olic
y and P roc
e d u re s M anu al and s tate m e nts for D ixon C C only paraphras e the
A d m inistrative D ire c
tive s . It inc
lu d e s nothings pe c
ificforD ixon C C and the ru nningofthe d e ntal
program . W he n as ke d , the d e ntald ire c
torkne w little ofits e xiste nc
e and had ne ve rre viewe d it.
Recommendations:
1. T hat the d e ntalprogram at D ixon C C d e ve lop ac
u rre nt d etaile d , thorou gh and ac
c
u rate
polic
y and proc
e d u re s m anu althat d e fine s how allas pe c
ts ofthe d e ntalprogram are to be
ru n and m anage d , to inc
lu d e ac
c
e s s to c
are , c
are provision, c
linicm anage m e nt, infe c
tion
c
ontrol, e tc
. O nc
e d e ve lope d , it s hou ld be re viewe d and u pd ate d on are gu larbas is and as
ne e d e d forne w polic
ies and proc
e d u re s .
Failed Appointments
A re view of m onthly re ports and d aily work s he e ts re ve ale d afaile d appointm e nt rate ofabou t
10.4% . A llfaile d appointm e nt inm ate s are re qu ire d to s ign are fu s alform . T he y are allloc
ate d and
brou ght to the d e ntalc
linicto d o so. T he s e pe rc
e ntage s are s lightly highand s hou ld be watc
he d .

B ec
au s e the d e ntalre c
ord is m aintaine d in the d e ntalc
alre c
ord ,
id e ntific
ation ofm e d ic
ally c
om prom ise d patients re lies on as s e s s m e nt by the c
linic
ian and on the
history s e c
tion on the c
ove rofthe d e ntalre c
ord . O fthe 10re c
ord s re viewe d ofinm ate s on antic
oagu lant the rapy, only one was ad e qu ate ly re d flagge d to c
atc
hthe im m e d iate atte ntion ofthe
provide r. Fou rofthe re c
ord s d id not ind ic
ate that the inm ate was on antic
oagu lant the rapy. Five
ofthe re c
ord s ind ic
ate d antic
oagu lant the rapy, bu t the y we re not s u ffic
iently re d flagge d . O n one
re c
ord , tre atm e nt was provide d and was m anage d properly.
linic
ians ind ic
Recommendations:
alhistory s e c
ord be kept u p to d ate and that m e d ic
al
c
ialpre c
atc
ofthe provide r. T he s e wou ld inc
lu d e m e d ic
ation alle rgies , antic
oagu lants , inte rfe ron
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 39
the rapy, pre -m e d ic

ate d c
ard iacc
ond itions and any othe r he alth c
ond ition that wou ld
re qu ire m e d ic
alinte rve ntion priorto d e ntaltre atm e nt.
2.
T hat blood pre s s u re re ad ings be rou tine ly take n of patients with a history of
hype rte ns ion,
e s pe c
alproc
e d u re .
Specialists
T he d e ntalprogram at D ixon C C u tilize s the Joliet O raland M axillo-fac
ialSu rge ry c
linicin Joliet,
Illinois. T his c
as e was the only one s e nt ou t in the pas t nine m onths . It was alarge c
ys t ofthe bod y
and ram u s ofthe m and ible , ave ry e xte ns ive s u rge ry. A llothe rs u rge ries , inc
lu d ingim pac
tions that
re qu ire re m oval, s u rgic
ale xtrac
tions and le s ion re m ovals , are d one in-hou s e by the d e ntists at
D ixon C C .
Recommendation: N one . Spe c
ialists are available and u tilize d .
Dental CQI
A re view ofm onthly m inu te s from the M e d ic
alC Q I C om m itte e re ve als that the d e ntalprogram
c
ontribu te s m onthly d e ntals tatistic
s to the C Q I c
om m itte e . W aitinglists are am ain c
onc
e rn. T he
waitinglist for e xtrac
tions and ope rative is e ight we e ks and for d e ntu re s is 12 we e ks . T he s e are
ve ry re as onable le ngths of tim e . N o c
onc
e rn was e xpre s s e d . T he d e ntal program re c
e ntly
c
om ple te d aC Q I stu d y that e valu ate d pe rc
e ntage ofre qu ire d d e ntu re ad ju s tm e nts at the tim e of
ins e rtion. Ins e rtions we re e valu ate d for Janu ary, Fe bru ary and M arc
h 2014. T hirty-s e ve n and a
halfpe rc
e nt ne e d e d s u c
had ju s tm e nts . T he s tu d y is s tillbe inge valu ate d to s e e ifany c
hange s c
an
be m ad e in the c
ons tru c
tion ord e live ry proc
e s s to im prove this pe rc
e ntage . N o othe rstu d ies are
ongoingat the tim e ofthis re port.
Recommendations:
1. T hat the C Q I proc
e s s be u s e d e xte ns ive ly to ad d re s s the program d e fic
ienc
ies ou tline d in
the bod y ofthis re port. P olic
ies and proc
e d u re s s hou ld be d e ve lope d from this proc
e s s to
ins u re that m e as u re s are in plac
e to m aintain program c
ontinu ity and im prove m e nt.

T he re have be e n no m e e tings s inc
e the re was am e e tingin D e c
e m be r of 2013, for whic
h we
re viewe d the m inu te s . T he m e e tingd e tails s u c
h things as the nu m be r of patients be ings e e n in
phys ic
ian or N P or nu rs e s ic
kc
allas we llas nu m be rs of s taff vac
anc
ies , nu m be rs of inc
id e nt
re ports , infe c
tion c
ontrold ataand othe rre ports ofs e rvic
e s provide d . T he re is no d oc
u m e ntation
ofany e fforts to inve s tigate e ithe rproc
e s s e s orprofe s s ionalpe rform anc
e noris the re any e ffort to
im prove e ithe rare a. T he ac
tingQ I c
oord inatoris am e m be rofthe nu rs ings taffwho has had no
trainingin C Q I m e thod ology and philos ophy. T he pre viou s m inu te s from be fore D e c
e m be r2013
we re in A u gu s t 2013 and s im ilarly c
ontaine d no e fforts inve s te d in im provingthe qu ality of
s e rvic
e s . T his c
an only be d e s c
ribe d as an inac
tive qu ality im prove m e nt program . Give n the
abs e nc
e oflogs to trac
k u ns c
e s orad e qu ate logs to re view s u c
h
things as the tim e line s s of s c
e s , s inc
e the d ate of ord e r is not available ,
atte m ptingto m onitorproc
e s s e s willbe qu ite ine ffic
ient. In ord e rto as s e s s intras ys te m trans fe rs
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 40
we had to obtain c
u s tod y re c
ord s ofpatients trans fe rre d in on agive n d ay. T he re is no intras ys te m
trans fe r logals o. T he C Q I program ne e d s to be c
om ple te ly re bu ilt afte r ke y s taff are provide d
trainingand the le ad e rs hippos itions are fille d .
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 41
Recommendations
1. M ake apriority of fillingthe vac
ant M e d ic
alD ire c
tor, H e alth C are U nit A d m inistrator,
D ire c
torofN u rs ing, N u rs e P rac
titione rand s e ve n, C orre c
tionalN u rs e I (R N )pos itions .
2. D u e to c
onc
e rns re gard ingnon-re giste re d nu rs e s c
ond u c
tings ic
kc
alland workingou ts id e
of the ir e d u c
ational pre paration and lic
e ns e d s c
ope of prac
tic
e and whe n all the
C orre c
tional N u rs e I pos itions are fille d , total re giste re d nu rs ingpos itions s hou ld be
e valu ate d as to the ne e d forad d itionalpos itions orare c
onfigu ringofc
u rre nt pos itions in
ord erto provide an allR N c
ond u c
te d s ic
kc
allproc
ess.
1. D e ve lopand im ple m e nt aplan to re plac
e the s tyle ofbe d s be ingu s e d forgeriatricpatients
on the third floorofthe m e d ic
albu ild ing.
2. P rope rly e qu ipd e s ignate d s ic
kc
allroom s in the he althc
are u nit and X -hou s e .
1. T he intras ys te m trans fe r proc
e d u re m u s t be gin with all ne wly trans fe rre d inm ate s be ing
pre s e nte d to the m e d ic
alu nit, whe re an appropriate re view ofthe trans fe r s u m m ary and
m e d ic
alre c
ord are d isc
u s s e d withthe patient, alongwithvitals igns be ingtake n, and whe re
ind ic
ate d , aplan be ingim ple m e nte d to ins u re c
ontinu ity ofs e rvic
e.
Medical Records:
1. M e d ic
alre c
ord s s taff s hou ld trac
k re c
e ipt ofallou ts ide re ports and e ns u re that the y are
file d tim e ly in the he althre c
ord .
2. C harts s hou ld be thinne d re gu larly and M A R s file d tim e ly.
3. P roble m lists s hou ld be ke pt u pto d ate .
Nursing Sick Call:
1. D e ve lopand im ple m e nt aproc
e d u re forone s tyle ofs ic
kc
all.
2. D e ve lopand im ple m e nt aplan foran allR N s ic
kc
allproc
ess.
3. D e ve lop and im ple m e nt aplan to as s u re non-m e d ic
al pe rs onne ld o not have ac
c
e s s to
inm ate s ic
kc
allre qu e s ts .
4. D e ve lopand im ple m e nt aplan to m aintain inm ate s ic
kc
allre qu e s ts on file .
5. D e ve lopand im ple m e nt aplan to initiate and m aintain as ic
kc
alllog.
6. In the X -hou s e , d e ve lopand im ple m e nt aplan to c
ond u c
t ale gitim ate s ic
kc
alle nc
ou nte r,
inc
lu d ing liste ning to the patient c
om plaint, c
olle c
ting a history and obje c
tive d ata,
pe rform ingaphys ic
ale xam ination whe n re qu ire d , m akingan as s e s s m e nt and form u lating
aplan oftre atm e nt rathe rthan the c
u rre nt prac
tic
e oftalkingto the patient throu ghas olid
s te e ld oorand bas ingany tre atm e nt on the c
onve rs ation only.
7. P e rO ffic
e ofH e althSe rvic
e s polic
y, as s u re alls ic
kc
alle nc
ou nte rs are d oc
u m e nte d in the
m e d ic
alre c
ord in the Su bje c
tive -O bje c
tive -A s s e s s m e nt-P lan (SO A P )s tyle .
8. D e ve lopand im ple m e nt aplan to as s u re the O ffic
e ofH e althSe rvic
e s approve d , preprinte d
tre atm e nt protoc
olform s are u s e d at e ac
hs ic
kc
alle nc
ou nte r.
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 42
9. D e ve lop and im ple m e nt aplan to as s u re e ac

h of apatient
s c
om plaints are ad d re s s e d
d u ringas ic
kc
alle nc
ou nte roraprioritization ofne e d s to ad d re s s d u ringfu tu re e nc
ou nte rs
is d e ve lope d rathe rthan the c
u rre nt prac
tic
e ofallowingonly one c
om plaint pe rvisit.
10. D e ve lopand im ple m e nt aplan ofe d u c
ation forallnu rs ings taffwhic
hwillbe c
ond u c
te d
by the M e d ic
alD ire c
torand ad d re s s e s the followingiss u e s :
a. A s s u re the patient
sc
om plaint is ad d re s s e d at the tim e ofthe s ic
kc
alle nc
ou nte r.
b. A s s u re d oc
u m e ntation is c
om ple te and , at am inim u m , ad d re s s e s the c
om plaint,
d u ration, history, pain le ve lifapplic
able , loc
ation ofpain, loc
ation ofinju ry, e tc
.,
c
olle c
tion ofc
om ple te vitals igns inc
lu d ingwe ight, an e xam ination if applic
able
and an as s e s s m e nt and plan.
c
. U s e ofthe O ffic
e ofH e althSe rvic
e s approve d tre atm e nt protoc
ols at e ac
hs ic
kc
all
e nc
ou nte r.
d . W he n u s ingthe protoc
ol, s taffm u s t c
om ply withthe O T C d os age s , as inc
re as ing
the s tre ngth or fre qu e nc
y m ake take the O TC d os age to an u nau thorize d
pre s c
ription d os age .
Clinician Sick Call:
1. T he nu rs ingd e partm e nt m u s t im ple m e nt as ic
kc
all logbook with field s inc
lu d ingd ate ,
patient nam e , patient nu m be r, re as on for visit, d ate of c
linician appointm e nt and if
c
anc
e lle d , re as on forc
anc
e llation and d ate forthe re s c
he d u le d appointm e nt.
Chronic Disease Program:
1. T he re s hou ld be as ingle nu rs e as s igne d to the c
hronicc
are program to ide ntify, e nroll,
m onitorand trac
k patients in an organize d and c
om pre he ns ive way.
2. P atients withH IV s hou ld be e nrolle d and m onitored in the c
hronicd ise as e program . T he re
s hou ld be as ys te m in plac
e to ide ntify m e d ic
ation nonc
om plianc
e (orothe rm iss e d d os e s )
and re fe rthos e patients to aprovide rtim e ly.
1. U ns c
e s re qu ire alogbook that c
ontains field s for d ate , tim e , patient nam e ,
patient nu m be r, pre s e nting s ym ptom , whe re the as s e s s m e nt was pe rform e d , and the
d ispos ition, inc
lu d ingif the patient was re tu rne d to the c
e llhou s e or s e nt offs ite . W he n
patients are s e nt offs ite , astaff pe rs on m u s t be as s igne d the re s pons ibility of obtaining
e ithe r the e m e rge nc
y room re port or, if the patient was ad m itte d to the hos pital, the
d isc
harge s u m m ary. A llpatients s e nt offs ite s hou ld be brou ght to the c
linicforanu rs e to
re view the re le vant d oc
u m e nts and ins u re the re qu ire d d oc
u m e nts , if not available , are
obtaine d and the patient is s c
he d u le d forafollow-u pvisit withaprim ary c
are c
linic
ian. A t
the prim ary c
are c
linic
ian visit, the c
linic
ian m u s t d oc
u m e nt ad isc
u s s ion ofthe find ings
and plan.
Scheduled Offsite Services:
1. T he d e lays in obtainings c
e s m u s t be e lim inate d . W e xford m u s t be
re qu ire d within s e ve n d ays afte rve rbalapprovalto have provide d au thorization to the U of
Ic
oord inator. If the U of I is as s igningan appointm e nt d ate gre ater than 30 d ays in the
fu tu re, an e ffort m u s t be m ad e to obtain the s ervic
e loc
ally. A fte rthe s ervic
e has be e n
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 43
provide d the patient s hou ld be re tu rne d throu gh the m e d ic

al c
linicand anu rs e s hou ld
re view the pape rwork ortake s te ps to obtain it. A fte rthe pape rwork is obtaine d , the patient
m u s t be s c
he d u le d forafollow-u pvisitwiththe prim ary c
are c
linic
ian, who m u s t d oc
u m e nt
the d isc
Infirmary Care:
1. Staffthe infirm ary withare giste re d nu rs e 24hou rs ad ay, s e ve n d ays awe e k.
2. E d u c
ation ofnu rs ings taffon the ne e d forc
om ple te c
harting, whic
hinc
lu d e s provid inga
thorou ghd e s c
ription ofthe patient
s m e d ic
alc
ond ition.
3. D e ve lopand im ple m e nt aplan to provide an ac
c
e s s ible nu rs e c
alls ys te m forpatients who
are phys ic
ally u nable to ac
c
e s s the c
u rre nt c
alls ys te m and provide for ac
re d ible s ys te m
forthos e patient room s withno nu rs e c
alls ys te m .
4. E s tablishm inim u m inve ntory le ve ls forbe d d ing, line ns and pillows and provid e ac
c
e ptable
ite m s whic
hare not torn, thre ad bare orfraye d .
5. P rovid e ape rm ane nt m anne d s e c
u rity pos t within the infirm ary.
6. D e ve lopand im ple m e nt aplan to obtain ne e d e d ad d itionale qu ipm e nt as d e te rm ine d by the
M e d ic
alD ire c
tor, H e althC are U nit A d m inistrator, D ire c
torofN u rs ingand anu rs ings taff
re pre s e ntative who is rou tine ly as s igne d to the infirm ary.
7. D e ve lop and im ple m e nt a plan to provid e ad d itional ins titu tional rad ios to infirm ary
nu rs ings taff.
Infection Control:
1. D e ve lopapos ition d e s c
ription and nam e an Infe c
tion C ontrolR e giste re d N u rs e (IC -R N ).
2. D e ve lopand im ple m e nt aplan forthe IC -R N to c
ond u c
t m onthly d oc
u m e nte d s afe ty and
s anitation ins pe c
tions foc
u s ingat a m inim u m on the he alth c
are u nit, infirm ary and
d ietary d e partm e nt with m onthly re porting to the Q u ality Im prove m e nt C om m itte e
(Q IC ).
3. D e ve lop and im ple m e nt aplan forthe IC -R N to m onitor food hand le r e xam inations and
c
le aranc
e forstaffand inm ate s .
4. D e ve lopand im ple m e nt aplan forthe IC -R N to m onitorc
om plianc
e withinitialand annu al
tu be rc
u los is s c
re e ning, with m onthly re portingto the Q IC and fac
ility ad m inistration as
ne e d e d .
5. D e ve lopand im ple m e nt aplan to aggre s s ive ly m onitors kin infe c
tions and boils and work
jointly with s e c
e s taff re gard ingc
e llhou s e c
le aningprac
tic
e s with
m onthly re portingto the Q IC and fac
ility ad m inistration as ne e d e d .
6. D e ve lop and im ple m e nt a plan to d aily m onitor and d oc
re ad ings whe n the room (s ) are oc
c
u pied for re s piratory isolation and we e kly whe n not
oc
c
u pied .
7. D e ve lop and im ple m e nt atrainingprogram for he alth c
are u nit porte rs whic
h inc
lu d e s
trainingon blood -borne pathoge ns , infe c
tiou s and c
om m u nic
able d ise as e s , bod ily flu id
c
le an-u p, prope r c
le aningand s anitizingof infirm ary room s , be d s , fu rnitu re , toile ts and
s howe rs .
8. M onitoralls ic
kc
allare as to as s u re appropriate infe c
tion c
ontrolm e as u re s are be ingu s e d
be twe e n patients i.e ., u s e ofpape ron e xam ination table s whic
his c
hange d be twe e n patients
oras pray d isinfe c
tant is u s e d be twe e n patients , e xam ination glove s are available to staff
and hand was hing/sanitizingis oc
c
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 44
9. D e ve lop and im ple m e nt aplan to m onthly m onitor allpatient c

are as s oc
iate d fu rnitu re ,
inc
lu d inginfirm ary m attre s s e s , to as s u re the inte grity ofthe prote c
tive ou te rs u rfac
e with
the ability to take ou t ofs e rvic
e and have re paire d orre plac
e d as ne e d e d .
10. Inte rfac
e with the C ou nty D e partm e nt of H e alth and Illinois D e partm e nt of H e alth and
provide re portingas re qu ire d by e ac
h.
1. T his program m u s t be re c
re ate d and provide d the le ad e rs hipthat has had trainingin qu ality
im prove m e nt philos ophy and m e thod ology. T he program s hou ld foc
u s on both proc
ess
im prove m e nt and profe s s ionalpe rform anc
e im prove m e nt as we llas grievanc
e re s pons e s .
T he program m u s t be u s e d to im prove intras ys te m trans fe rs , bothnu rs e and provid e rs ic
k
c
all, the c
hronicc
are program , infirm ary c
are , u ns c
es c
are , s c
he d u le d offs ite
s e rvic
es c
are , m e d ic
alad m inistration, grievanc
e s , infe c
tion c
ontrol, d e ntals e rvic
e s and
m e ntalhe alths e rvic
e s . T his program re qu ire s the u s e oflogbooks fortrac
kingc
apabilities
forbothintras ys te m trans fe rs , s ic
kc
all, infirm ary c
are , c
hronicc
are , u ns c
es
c
are , s c
e s and grievanc
es.
c
olle c
tion.
s trate gies .
Febru ary 2014
Di
xon C orrec ti
onalC enter
P age 45

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Nursing Sick Call:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Clinician Sick Call:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
Name
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Chronic Disease:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
Febru ary 2014
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Di
xon C orrec ti
onalC enter
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P age 46
Unscheduled Offsite Service:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redact
Infirmary:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
P atient #11
P atient #12
Febru ary 2014
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Di
xon C orrec ti
onalC enter
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P age 47
Pontiac Correctional Center

(PCC) Report
April 3, 4, 14-16, 2014

Ron Shansky, MD
Karen Saylor, MD
Larry Hewitt, RN
Karl Meyer, DDS
Contents
Overview....................................................................................................................................3
Findings .....................................................................................................................................6
C linicSpac
e and Sanitation .....................................................................................................7
N u rs ingSic
k C all.....................................................................................................................9
P harm ac
y/M e d ic
Laboratory .............................................................................................................................17
Sc
e d u re s ).................................................. 19
Infirm ary C are .......................................................................................................................20
Infe c
tion C ontrol...................................................................................................................22
Inm ate s Inte rviews ...............................................................................................................22
D e ntalP rogram ......................................................................................................................23
M ortality R e view ...................................................................................................................30
A pril2014
P onti
ac C orrec ti
onalC enter
P age 2
Overview
O n A pril3-4and 14-16, 2014, we visite d P ontiacC orre c
tionalC e nte r(P C C ). T his was ou rfirs t
s ite visit to P C C and this re port d e s c
om m e nd ations . D u ringthis visit,
we :
al
als e rvic
e s are a
are s taff
u m e nts
W e thank W ard e n P ierc

e and his s taff for the ir as s istanc
e and c
oope ration in c
ond u c
tingthe
re view.
Executive Summary
P C C is a m axim u m -s e c
u rity prison that hou s e s approxim ate ly 2000 offe nd e rs . T he c
u rre nt
popu lation was 2035 inm ate s . T he ins titu tion is not are c
e ption c
e nte r bu t has an infirm ary and
m e ntalhe althm iss ion.
T he H e althC are U nit is an old two-story bu ild ingwhic
hwas re m od e le d and ope ne d in the late
1980s , and the re appe ars to have be e n little to no re novation s inc
e its ope ning.
T he re are m inim al s taffingvac
anc
ies at P ontiac
. T he M e d ic
al D ire c
tor and H e alth C are U nit
A d m inistrator(H C U A )pre s e nt astrongad m inistrative le ad e rs hipte am ;howe ve r, the D ire c
torof
N u rs ing(D O N )d id not appe arto fu nc
tion as apart ofthat te am . T he D O N , who is e m ploye d by
the m e d ic
alve nd or, has be e n on s ite 18 m onths bu t als o fu nc
tions as the m e d ic
alve nd or
s s ite
m anage r, whic
hs ignific
antly im pac
ts on he rability to pe rform the D O N d u ties .
T he re are nine C M T s e m ploye d at this fac
ility, two-third s ofwhom are LP N s. A lthou ghwe we re
told othe rwise , C M T s are pe rform ings ic
kc
all. T he re is one phys ic
ian, the M e d ic
alD ire c
tor, who
fu nc
tions alm os t e xc
lu s ive ly in ac
linic
alc
apac
ity, followingthe infirm ary and m e d ic
ally c
om ple x
c
hronicc
are patients . H e als o d oe s u rge nt c
are /trau m a. H e works s ix d ays pe rwe e k.
T he m ajority ofc
are is provide d in the c
e llhou s e s . T he re are e xam room s in e ac
hc
e llhou s e ,
m os tly c
onve rte d bathroom s and s torage room s . T he c
e llhou s e c
linic
s have old and d ilapid ate d
e qu ipm e nt;the e xam table s are ac
tu ally phys ic
althe rapy table s that d o not inc
line . N one ofthe
table s had pape r. T he M e d ic
alD ire c
tors e e s s ic
kc
allpatients in the H C U and u s u ally s e e s abou t
10 s c
he d u le d patients pe r d ay;the nu m be r is lim ite d bas e d on the re s tric
tions on m ove m e nt, as
e ac
h patient has to be e s c
orte d ind ivid u ally. A typic
al volu m e for ac
e llhou s e c
linicis 10-12
ac
c
ord ingto the H C U A . T he large m ajority ofthe c
hronicc
are c
linic
s are d one by the m id le ve l
provide rs .
A pril2014
P onti
ac C orrec ti
onalC enter
P age 3
W e fou nd boththe M e d ic
alD ire c
torand nu rs e prac
titione rto be c
om pe te nt and thorou gh, with
s olid c
linic
ald e c
ision-m akings kills . W e fou nd the P A
s note s to be lac
kingin d e tailand had
s om e c
onc
e rns re gard inghis c
linic
al ac
u m e n and the re fore obs e rve d him in ac
tion, with his
pe rm iss ion and that ofthe patients , d u ringhis c
linic
. W hat we obs e rve d was s om e ofthe m os t
c
onfrontational, argu m e ntative and u nprofe s s ionalbe havior from ahe althc
are provid e rthat we
have s e e n in re c
e nt m e m ory. H is be haviorwas not only u nprofe s s ionalbu t als o u ns afe in aprison
e nvironm e nt. In ou ropinion, this provid e rs hou ld not be prac
tic
ingin ac
orre c
tionals e tting.
M e d ic
alre c
ord s we re ord e rly, ne at and we llm aintaine d . H owe ve r, ofte n the proble m lists we re
not u pto d ate .
T he c
u rre nt intras ys te m trans fe rproc
e s s d oe s not e ffe c
tive ly ins u re appropriate and tim e ly followu pforide ntified proble m s .
Sic
kc
allc
ons ists ofC orre c
tionalM e d ic
alT e c
hnic
ians (C M T s ), who c
ou ld be e ithe r aLic
e ns e d
P rac
tic
alN u rs e (LP N ) or c
e rtified E m e rge nc
y M e d ic
alT e c
hnic
ian (E M T ), who is as s igne d to
s pe c
ificc
e llhou s e s , c
olle c
tingwritte n inm ate he althc
are re qu e sts orliste ningto ve rbalre qu e s ts
and re viewingthe re qu e s ts as to whe the rthe re is an u rge nt orrou tine ne e d . Ifu rge nt, the inm ate
is e s c
orte d to the H e althC are U nit fore valu ation. Ifrou tine , the C M T provide s tre atm e nt bas e d
on approve d ID O C O ffic
e ofH e althSe rvic
e s tre atm e nt protoc
ols . A llofthe s e ac
tions are be yond
the s c
ope ofe d u c
ationalpre paration and prac
tic
e fore ithe ran LP N orE M T, and ac
c
e s s to he alth
c
are is d e laye d d u e to inappropriate as s e s s m e nt.
C hronicc
are c
linic
s we re oc
c
u rringtim e ly withlabs d rawn tim e ly priorto the visits in m os t c
as e s .
T he re is no c
hronicc
are nu rs e ;the H C U A fu nc
tions in this c
apac
ity. A lthou ghs he d oe s agood
job, we re c
om m e nd that the re be anu rs e d e d ic
ate d to this pos ition, give n the volu m e of work
e ntaile d . T he re is no s ys te m in plac
e to trac
k im portant ind ic
ators ofthe c
hronicc
are c
linic
s s u ch
as d e gre e of d ise as e c
ontrol or variou s ou tc
om e s m e as u re m e nts . T his m ake s it im pos s ible to
obje c
tive ly m e as u re how we llthe popu lation is m anage d as awhole . In the c
ou rs e ofou r c
hart
re views , we c
am e ac
ros s m u ltiple c
as e s whe re in im portant laboratory find ings we re not ad d re s s e d ,
and s e ve ral avoid able inte rru ptions in tre atm e nt of patients with H IV infe c
tion and s e izu re
d isord e rs , am ongothe rproble m s .
P harm ac
e u tic
als are provid e d by the m e d ic
alve nd orthrou ghB os we llP harm ac
e u tic
als loc
ate d in
P itts bu rg, P A . It is afax and fill s ys te m , whic
hm e ans pre s c
riptions faxe d to B os we llby 2:00
p.m . willbe re c
e ive d at the fac
ility the ne xt d ay. A c
om m u nity re tailpharm ac
y and the loc
al
hos pitalare u s e d as bac
k-u pprovide rs . T he m e d ic
ation s torage /pre paration room is m anage d by
apharm ac
y te c
hnic
ian who has 13 ye ars of e xpe rienc
e in the field . T he re was tight c
ontrolof
m e d ic
ation, s harps and m e d ic
altools , withallpe rpe tu alinve ntories be ingac
c
u rate .
Laboratory s e rvic
e s are provide d by the U nive rs ity of Illinois-C hic
ago (U IC ). D aily, M ond ay
throu ghFriday, s pe c
im e ns are d rive n to U IC and re ports are faxe d to the fac
ility, ge ne rally the
ne xt d ay.
A pril2014
P onti
ac C orrec ti
onalC enter
P age 4
T he u ns c
he d u le d offs ite and ons ite s e rvic
e s allowe d for id e ntific
ation ofthe followingtype s of
proble m s :m iss inge s s e ntiald oc
u m e ntation, d e lays in obtainingre qu ire d s e rvic
e s and an abs e nc
e
offollow throu ghon re c
om m e nd ations by as pe c
ialist, withou t the pre s e nc
e ofan e xplanation of
an alte rnative approac
h.
W ithre gard to s c
e s , we ide ntified d e lays in obtainingappointm e nts and als o
d e lays in obtainingre ports and ad e lay in ac
c
e s s to aproc
e d u re .
T he infirm ary, whic
his loc
ate d on the firs t floorofthe H C U , is a12-be d u nit s taffe d withat le as t
one re giste re d nu rs e 24hou rs ad ay, s e ve n d ays awe e k. Se c
u rity s taffis pre s e nt in the infirm ary,
withinm ate porte rs pe rform ingthe janitoriald u ties and s u pe rvise d by bothnu rs ingand s e c
u rity
s taff.
T he infirm ary be d s are in ve ry poorc
ond ition and ne e d to be re plac
e d . T he re is only one be d that
c
ou ld be c
ons id e re d ahos pitalbe d whic
hallows forraisingand lowe ringthe he ad orfoot ofthe
be d . T he re is no fu nc
tion to raise or lowe r the c
om ple te be d . A d d itionally, the re are m any
m attre s s e s with c
rac
ke d or torn plas ticc
ove rings and m any m attre s s e s with no plas ticou te r
c
ove ring. T his pre s e nts a s ignific
ant infe c
tion c
ontrol iss u e s , as the m attre s s e s c
annot be
e ffe c
tive ly d isinfe c
te d .
T he s ink in the nu rs ings tation, whic
his u s e d forhand was hing, c
ou ld not be u s e d be c
au s e it wou ld
not d rain and it le ake d . A d d itionally, the re is no nu rs e c
alls ys te m in the infirm ary and the re is
not d ire c
t line -of-s ight from the nu rs ings tation into e ac
hroom .
T he H C U A fu nc
tions as the infe c
tion c
ontrolnu rs e . She re porte d aggre s s ive m onitoring, c
u ltu ring
and tre atm e nt ofs kin infe c
tions and boils . She als o re porte d alow oc
c
u rre nc
e ofc
u ltu re prove n
M R SA .
Infirm ary be d d ingand line ns are lau nd e re d by inm ate porte rs in a re s ide ntial s tyle was hing
m ac
hine loc
ate d in the infirm ary. W ate r te m pe ratu re s are not s u ffic
ient to properly s anitize the
Inm ate porte rs who pe rform s the he althc
are u nit janitoriald u ties have re c
e ive d no trainingon
the prope rs anitation ofinfirm ary room s , be d s , fu rnitu re and line ns , infe c
tiou s and c
om m u nic
able
d ise as e s , blood -borne pathoge ns , bod ily flu id c
le an-u pand m e d ic
alc
onfid e ntiality.
T he C Q I program ne e d s to e ffe c
tive ly ide ntify proble m s and analyz e the irc
au s e s and im ple m e nt
im prove m e nt strategies s o that the proble m s ide ntified above are u ltim ate ly m itigate d .
A grou p inte rview with s ix ins u lin d e pe nd e nt d iabe tic
s ind ic
ate d age ne ral c
ons e ns u s that the
phys ic
ian and nu rs ings taffatte m pte d , within the s ys te m , to provide the m withgood c
are. T he y
we re allope nly c
ritic
altoward the P hys ic
ian
s A s s istant in re gard to his attitu d e and c
om pe te nc
e.
A pril2014
P onti
ac C orrec ti
onalC enter
P age 5
Findings
T he M e d ic
alD ire c
tor pos ition was fille d with an e xpe rienc
e d phys ic
ian with abac
kgrou nd in
inte rnalm e d ic
ine who has worke d in the c
orre c
tionals ys te m s inc
e the m id -1980s . H e pe rform s
bothc
linic
alwork as we llas M e d ic
alD ire c
torR e s pons ibilities and ofc
ou rs e the re is s om e ove rlap.
B e s id e s his s tric
tly c
linic
alre s pons ibilities provid ingprim ary c
are s e rvic
e s , we d isc
u s s e d his view
ofhis re s pons ibilities as M e d ic
alD ire c
tor. H e ind ic
ate d the s e re s pons ibilities inc
lu d e d following
u pon alloffs ite re fe rrals , boths c
he d u le d and u ns c
he d u le d , as we llas be ingre fe rre d c
as e s whic
h
we re pe rc
e ive d by the othe r prim ary c
are c
linic
ians as too d iffic
u lt or c
om ple x. H e als o was
re s pons ible fore valu atingany alle ge d rape c
as e s . H e m ake s rou nd s in the infirm ary on allpatients .
H e als o atte nd s qu ality im prove m e nt m e e tings, re views all nu rs e prac
titione r and phys ic
ian
as s istant re fe rrals for s c
e s and the n pre s e nts the s e c
as e s at the c
olle gial
re view d isc
u s s ions with the u tilization m anage m e nt phys ic
ians in P itts bu rgh for W e xford . H e
ind ic
ate s that he d oe s not d o are gu larre view withfe e d bac
k to the nu rs e prac
titione rand phys ic
ian
as s istant;thu s , the re is no organize d e ffort to as s ist the m in im provingthe irs kills . H e works for
W e xford .
A ls o on s ite is aH e althC are A d m inistratorwho has worke d bothforthe ve nd orand forthe s tate
and appe ars to be qu ite knowle d ge able and he avily involve d in the s e rvic
e s be ingprovide d .
Finally, the re is als o aD ire c
torofN u rs ingpos ition fille d by the ve nd orand the D ire c
torofN u rs ing
als o is re s pons ible , as the W e xford s ite m anage r, for hand lingoffic
e re s pons ibilities s u c
h as
tim e ke e pingand payroll. T his was the firs t fac
ility ofthe five we have be e n to in whic
hallofthe
le ad e rs hippos itions we re fille d at the tim e ofou rvisit.
Position
M e d ic
alD ire c
tor
StaffP hys ic
ian
P hys ic
ian
s A s s t.
N u rs e P rac
titione r
D ire c
torofN u rs ing
O ffic
e A s s oc
iate
C orre c
tions N u rs e II
Lic
e ns e d P rac
tic
alN u rs e s
C orre c
tionalM e d ic
alT e c
hnic
ian
.
P hle botom ist
A pril2014
Current FTE
1.0
0
1.0
1.0
1.0
1.0
1.0
1.0
6.0
Filled
1.0
0
1.0
1.0
1.0
1.0
0
1.0
5.0
13.0
2.0
11.0
1.0
1.0
0.5
11.0
2.0
9.0
1.0
1.0
0.5
P onti
ac C orrec ti
onalC enter
Vacant
0
0
0
0
0
0
1
0
1-LO A
4yrs .
2
0
2
0
0
0
State/Cont.
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
State
C ontrac
t
C ontrac
t
State
State
C ontrac
t
C ontrac
t
State
C ontrac
t
State
C ontrac
t
P age 6
Position
R ad iology T e c
hnic
ian
P harm ac
y Tec
hnic
ian
P harm ac
y Tec
hnic
ian
StaffA s s istant I
C hiefD e ntist
D e ntist
D e ntalH ygienist
O ptom e try
StaffA s s istant
O ffic
e C oord inator
Total
Current FTE
0.3
2.0
Filled
0.3
2.0
Vacant
0
0
1.0
3.0
1.0
0.6
2.0
1.0
0.2
5.0
1.0
58.6
0
3.0
1.0
0.6
2.0
1.0
0.2
5.0
1.0
51.6
1
0
0
0
0
0
0
0
0
7
State/Cont.
C ontrac
t
C ontrac
t
State
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
T he re are m inim alvac

anc
ies at P ontiac
. T he M e d ic
alD ire c
torand H e althC are U nit A d m inistrator
pre s e nt a strongle ad e rs hip te am . T he D ire c
tor of N u rs ing, who is e m ploye d by the m e d ic
al
c
ontrac
tor, has be e n ons ite 18m onths bu t d oe s not fu nc
tion as an inte gralpart ofthe he althc
are
te am . O fpartic
u larc
onc
e rn, the D ire c
torofN u rs ingals o fu nc
tions as the m e d ic
alc
ontrac
tors ite
m anage r. T hat pos ition alone is qu ite d e m and ingand , as are s u lt, le ave s little tim e for he r to
ac
tive ly fu nc
tion as aD ire c
torofN u rs ing. D u ringthe ins pe c
tion, s he was c
ons pic
u ou s ly abs e nt
the m ajority ofthe tim e .

T he he althc
are u nit is an old two story bu ild ingre m od e le d and ope ne d in the late 1980s . T he firs t
floor c
ontains as e c
u rity post, thre e inm ate hold ingare as , an u rge nt c
are /e m e rge nc
y room , an
optom e try c
linic
, te le m e d ic
ine c
linic
, a large m e d ic
ation s torage room , H e alth C are U nit
A d m inistratoroffic
e , D ire c
torofN u rs ingoffic
e , thre e -c
hair d e ntalc
linic
, rad iology room and a
12 be d infirm ary. T he s e c
ond floor hou s e s a large c
onfe re nc
e room and m u ltiple offic
e s for
m e d ic
aland m e ntalhe alths taff.
D e s pite the age , the bu ild ingis c
le an, we lllighte d and ge ne rally we llm aintaine d .
Inm ate porters , u nd e r the s u pe rvision of both s e c
u rity and nu rs ings taff, pe rform the janitorial
d u ties ;porters d o not perform orare involve d in any m e d ic
alc
are d e live ry. P orters are provide d no
orientation to the he alth c
are u nit or prope r c
le aningand s anitation proc
e d u re s , blood -borne
pathoge n trainingorc
om m u nic
able d ise as e training. W he n ind ic
ate d , the y are provide d pe rsonal
prote c
tive e qu ipm e nt and s u pe rvise d by nu rs ings taffwhe n c
le aningu pblood orbod y flu ids .
P orte rs are re s pons ible for lau nd e ringinfirm ary line ns . T he prac
tic
e is of c
onc
e rn s inc
e it is
d ou btfu lthe was hingm ac
hine wate rte m pe ratu re is hot e nou ghto appropriate ly s anitize infirm ary
line ns . A ll infirm ary line ns and be d d ingm u s t be c
ons ide re d to be c
ontam inate d . T he re qu ire d
lau nd e ringproc
e d u re to s anitize line ns and be d d ingis to was hwithlau nd ry d e te rge nt at awate r
te m pe ratu re ofat le as t 160d e gre e s Fahre nhe it foram inim u m of25m inu te s orwas hwithlau nd ry
d e te rge nt and able ac
h bath of at le as t 100 ppm at awate r te m pe ratu re of at le as t 140 d e gre e s
Fahre nhe it foram inim u m of10m inu te s . T he hot wate rte m pe ratu re s forthe
A pril2014
P onti
ac C orrec ti
onalC enter
P age 7
infirm ary was hingm ac

hine ne e d to be initially c
he c
ke d and rou tine ly m onitore d to as s u re e ithe r
140-d e gre e wate rte m pe ratu re withable ac
hbathor160-d e gre e wate rte m pe ratu re withno ble ach
bath. It is d ou btfu lthe c
u rre nt wate rte m pe ratu re is ove r125-130d e gre e s . Ifthe appropriate wate r
te m pe ratu re c
annot be attaine d , infirm ary line ns and be d d ing m u s t be lau nd e re d in the
ins titu tionallau nd ry whe re , again, the appropriate wate rte m pe ratu re s m u s t be m aintaine d .
From as afe ty and m e d ic
als e rvic
e s d e live ry pe rs pe c
tive , the s tretc
he r in the u rge nt c
are room
ne e d s to be re plac
e d . T he re are no workings id e rails , and the m attre s s e as ily s lid e s offthe s tretc
he r.
ord s ofpatients who had trans fe rre d into P ontiacwithin the priorthre e m onths .
In this re view we are prim arily d e te rm iningwhe the r the intras ys te m trans fe r proc
e s s fac
ilitate s
c
ontinu ity forallre qu ire d s e rvic
e s . In s ix ofthe 12re c
ord s we ide ntified proble m s whic
hre late d
to arrangingforappropriate follow-u p.
Patient #1
T his is a47-ye ar-old who arrive d at P ontiacon 2/11/14withane wly pos itive T B s kin te s t. H is xray was ne gative , bu t he had ne ve rbe e n e valu ate d by aprim ary c
are provide rwho wou ld d isc
u ss
withhim the natu re and re qu ire d follow u pforthe pos itive T B s kin te s t.
Patient #2
T his is a46-ye ar-old whos e proble m list c
ontains the proble m s ofre d u c
e d plate le ts and athroat
tu m or. H e arrive d at P ontiacon 2/19/14. In e arly N ove m be r2013, ale s ion was fou nd in his m ou th
whic
hwas thou ght to be atu m or. H e we nt to Lawre nc
e M e m orialH os pitalon 11/13/13 witha
proble m of ble e d ing. H e was give n two u nits of blood trans fu s ions and trans fe rre d to the C arl
C linic
, whe re he s taye d approxim ate ly a m onth. H e u ltim ate ly was give n the d iagnos is of
throm boticthrom boc
ytope nicpu rpu raas we llas H . pyloriinfe c
tion, ane m iaand hype rte ns ion. A t
the C arlC liniche had plas m aphe re s is and was give n pre d nisone , Las ix, C ore gand proton pu m p
inhibitors . A t the tim e ofd isc
harge he was s tillane m ic
, withahe m oglobin of9.1and ahe m atoc
rit
of30. O n d isc
harge he was ad m itte d to the D anville infirm ary, whe re he had ac
e ntralline port
ins talle d u ntilju s t be fore he was trans fe rre d to P ontiacon 2/14/14. A t the tim e oftrans fe r, he was
on iron for ane m iaand he als o had d e c
re as e d nu m be rs of plate le ts . A lthou gh the proble m list
c
ontains atu m orin the m ou th, the re has be e n no follow-u pto c
onfirm orind ic
ate the proble m has
re s olve d .
Patient #3
T his is a 46-ye ar-old with a s e izu re d isord e r and hype rthyroid ism . H e arrive d on 2/26/14 at
P ontiac
. H e has ne ve rhad ac
hronicc
are visit d e s pite e nte ringthe s ys te m in D e c
e m be r2013.
Patient #4
T his is a54-ye ar-old with hype rte ns ion who arrive d at P ontiacon 2/26/14. D e s pite havingthe
hype rte ns ion and e nte ringthe s ys te m in e arly Fe bru ary, he has ne ve rhad ac
hronicc
are visit.
A pril2014
P onti
ac C orrec ti
onalC enter
P age 8
Patient #5
T his is a43-ye ar-old with he patitis C and throm boc
ytope nia. H e arrive d at P ontiacon 2/11/14.
T he P ontiactrans fe rs u m m ary d oe s not inc
lu d e his havinghe patitis C . H is las t he patitis C c
hronic
c
are visit was in Ju ly of2013. H is m os t re c
e nt laboratory te s ts we re in Janu ary.
Nursing Sick Call

O n ad aily bas is, C orre c
tionalM e d ic
alT e c
hnicians (C M T s ), who c
ou ld be lic
e ns e d oru nlic
e ns e d ,
tou rthe iras s igne d c
e llhou s e s forinm ate he althc
are c
om plaints . Inm ate s voic
e the irc
om plaints
to the C M T throu ghe ithe ran ope n c
e ll-front barre d d oororas olid d oor. B as e d on the natu re of
the c
om plaint or re qu e s t, the C M T c
ou ld m ake the d e c
ision to im m e d iate ly re fe r the inm ate to
the phys ic
ian orm id -le ve lprovid e r, re fe rthe inm ate fornu rs e s ic
kc
alloru s e an approve d O ffic
e
ofH e althSe rvic
e s tre atm e nt protoc
olto tre at the inm ate . O bs e rvation ofthe proc
e s s in N orthC e ll
H ou s e s howe d a non-lic
e ns e d C M T liste ningto inm ate he alth c
are c
om plaints at c
e ll s id e .
D e pe nd ingon the natu re ofthe c
om plaint, vitals igns m ay orm ay not be take n. T he inm ate is not
brou ght ou t ofthe c
e lland , as are s u lt, aphys ic
ale xam ination and as s e s s m e nt is not pe rform e d ;
howe ve r, the C M T m ay u s e an approve d tre atm e nt protoc
oland provid e tre atm e nt, inc
lu d ing
ove r-the -c
ou nte r m e d ic
ation, in the abs e nc
e of any obje c
tive find ings and s ole ly bas e d on the
inm ate
s s u bje c
tive c
om m e nts . O f15re c
ord s re viewe d , the followingiss u e s we re id e ntified .
1. In all15 re c
ord s , the e nc
ou nte r was pe rform e d by aC orre c
tional M e d ic
al T e c
hnic
ian
(C M T )who c
ou ld be aLic
e ns e d P rac
tic
alN u rs e (LP N )oru nlic
e ns e d s taffm e m be rs who
are c
e rtified E m e rge nc
y M e d ic
al T e c
hnicians . C M T s are liste ning to c
om plaints ,
c
olle c
tings u bje c
tive d ataand , bas e d on the inm ate
s c
om plaint and the s u bje c
tive d ata,
m akingan as s e s s m e nt and bas e d on the as s e s s m e nt m akingad e c
ision to tre at the inm ate
from atre atm e nt protoc
ol. P u rs u ant to the Illinois N u rs e P rac
tic
e A c
t, pe rform ingthe s e
fu nc
tions is be yond the e d u c
ope ofprac
tic
e forLP N s and E M T s .
2. In all 15 re c
ord s , the e nc
ou nte r inc
lu d ingc
olle c
tion of vital s igns and any phys ic
al
as s e s s m e nt was pe rform e d at c
e lls id e e ithe r throu gh ope n-bar d oors or in one ins tanc
e
throu ghasolid d oorby way ofthe food hatc
h.
3. In thre e of 15 re c
ord s , tre atm e nt was provid e d bas e d only on the inm ate
s s u bje c
tive
c
om m e nts .
4. In thre e ofthe 15re c
ord s , vitals ign d oc
u m e ntation was inc
om ple te .
5. In fou rofthe 15re c
ord s , the phys ic
alas s e s s m e nt was inc
om ple te .
6. In one of the 15 re c
ord s , the c
ontac
t was postpone d d u e to loc
kd own. T he patient was
e valu ate d fou rd ays late r.
7. In only thre e of the 15 re c
ord s was the inm ate re fe rre d to the phys ic
ian or m id -le ve l
provide r.
A s are s u lt ofthe above , it is ou ropinion that ac
c
e s s to he althc
are is d e laye d d u e to inappropriate
as s e s s m e nt.
P e rID O C polic
y, $5.00c
o-pay is c
harge d fornon-e m e rge nc
y, s e lf-ge ne rate d s ic
kc
allre qu e s ts .
A pril2014
P onti
ac C orrec ti
onalC enter
P age 9

It was not pos s ible to d eterm ine how m any patients are e nrolle d in the program , as the O T S d oe s
not have the c
apac
ity to sort the d atathis way. It als o d oe s not trac
k any d e tails re gard ingthe c
hronic
c
are c
linic
, su c
has the d e gre e ofc
ontrol, etc
. T he re is no d e d ic
ate d c
hronicc
are nu rs e ;the H C U A
fu nc
tions in this c
apac
ity. She ke e ps logbooks foreac
hc
hronicc
are c
linicwhic
htrac
k the d ate e ac
h
patient was las t s e e n and som e d etails abou t the ir d e gre e ofc
ontrolorothe rc
linic
s the patient is
e nrolle d in. If patients have m u ltiple c
hronicd ise as e s , the y are allad d re s s e d at the tim e of the
c
hronicc
are c
linicvisit. T he d istribu tion ofpatients in the c
linic
s is as follows :
C ard iac
D iabe te s (76)
Ge ne ralM e d ic
ine (240)
H IV Infe c
tion/A ID S (16)
Live r(54)
T B Infe c
tion (76)
C hronicc
are c
linicare oc
c
u rringtim e ly withlabs d rawn be fore e ac
hc
linic
. A llm e d ic
ations are
re ne we d at the tim e ofthe c
hronicc
are visit. P roble m lists we re ge ne rally not u pto d ate . T he P A
s
e xam s we re m inim al;m os t organ s ys te m s we re d e s c
ribe d as only wnl (within norm allim its ).
T he nu rs e prac
titione r
s we re s om e what be tte r.
Cardiovascular/Hypertension
W e re viewe d s e ve n c
harts of patients e nrolle d in the hype rte ns ion c
linic
. N one had u pd ate d
proble m lists bu t allwe re s e e n e ve ry fou r m onths pe r polic
y. P hys ic
ale xam s we re m inim alin
m any c
as e s . W e we re partic
u larly trou ble d by one c
as e d e s c
ribe d be low (patient #2).
Patient #1
T his is a67-ye ar-old m an withc
oronary arte ry d ise as e , hype rte ns ion, ankylos ings pond ylitis and
C K D . H is proble m list was las t u pd ate d in 2009. H e is on Las ix pre s u m ably forahistory ofhe art
failu re , bu t the re is no e c
ho re port in the c
hart. D e s pite his d iagnos is ofc
oronary arte ry d ise as e
withpriorste nt, he was not pre s c
ribe d abe ta-bloc
ke r, statin orA C E inhibitor.
Opinion:T his patient s hou ld be on ad d itionalm e d ic
ations to d e c
re as e his risk of fu tu re c
ard iac
e ve nts .
Patient #2
T his is a 72-ye ar-old m an with c
oronary artery d ise as e , hype rte ns ion, C O P D and ahistory of
prostate c
anc
e r. H e had an M I in N ove m be r 2012, aste nt in 2011and aC A B G in 2002. H e was
pre s c
ribe d fu lld os e as pirin, P lavix and 600m gofibu profe n twic
e ad ay, am ongnu m e rou s othe r
m e d ic
ations . H e has be e n s e e n e ve ry fou rm onths in c
hronicc
are c
linicforhis variou s d ise as e s .
A t the 10/3/13visit, he had labs prior(on 9/18)whic
hre fle c
te d ad ropin his H bto 9.2g/d l(d own
from 12.8g/d lin M ay). T his was not m e ntione d d u ringthe visit, thou ghthe labre port had
A pril2014
P onti
ac C orrec ti
onalC enter
P age 10
be e n s igne d on 9/20. O n 10/23, the d oc

tors aw him again forwe akne s s afte rprolonge d s tand ing.
A gain, the ane m iawas not m e ntione d .
O n 12/2, the patient s aw the P A forfollow u pofhis hype rte ns ion and re porte d ongoingwe akne s s .
T he P A note d the low H bbu t d id not d o are c
tale xam to te st the stoolforblood . H e ord e re d re pe at
labs and afollow u pvisit in one m onth. T he labs we re not d one .
O n 12/9, the patient s aw the nu rs e prac
titione rforfollow u pofhis abnorm allabs . She als o note d
the d rop in H b from M ay to Se pte m be r and note d that the patient was taking the
as pirin/P lavix/M otrin c
om bination. H e ras s e s s m e nt was ane m ia, r/o GI ble e d ,bu t s he d id not d o
are c
tale xam . She d e c
re as e d the as pirin to 81 m g, stoppe d the ibu profe n and ord e re d follow u p
forone we e k.
O n 12/10, are pe at C B C s howe d that the H bhad d roppe d fu rthe rto 8.1g/d land the W B C c
ou nt
was e le vate d at 16.2. T wo d ays late r, the re is anote from the s am e nu rs e prac
titione rwho re viewe d
the s e re s u lts and foc
u s e d e ntire ly on the W B C e le vation and e m barke d on awork-u pto ru le ou t
infe c
tion. T he ane m iawas not m e ntione d . H owe ve r, the patient was s e e n that s am e d ay by the
M e d ic
alD ire c
torwho ad m itte d him to the infirm ary withfe ve rof102.7 and kne e pain. H e als o
note d the ane m iabu t d id not d o are c
tale xam , foc
u s ingins te ad on the pos s ibility ofas e ptickne e .
Labs we re re pe ate d the d ay ofthe infirm ary ad m iss ion and the H bwas d own to 7.9g/d lbu t not
ad d re s s e d .
O n 12/24, he pre s e nte d to the he althc
are u nit withc
he s t pain and was s e nt to the loc
alhos pital,
whe re he was fou nd to be in ac
u te re nalfailu re withac
re atinine of4(u pfrom bas e line of1-1.5),
and ane m iawithan H bof7. H e was give n IV Fand his re nalfailu re im prove d . H e was d isc
harge d
bac
k to the prison with a re c
om m e nd ation that he u nd e rgo an ou tpatient c
olonos c
opy. T he
d isc
harge s u m m ary was re viewe d by the nu rs e prac
titione r u pon the patient
s re tu rn bu t the re is
no m e ntion ofthe ane m iaand re c
om m e nd ation forc
olonos c
opy. O n 12/31, the P A s aw the patient
forawrit retu rn and als o foc
u s e d e xc
lu s ive ly on the re nalfailu re withno m e ntion ofthe ane m ia.
O n 1/12/14, the patient was ad m itte d to the infirm ary forre c
u rre nt kne e pain. Labs d rawn the ne xt
d ay s howe d an H bof8.4and W B C of12.1. T he M e d ic
alD ire c
tornote d iron d e fic
ienc
y ane m ia
and ord e re d iron s u pple m e ntation;no re c
tale xam orothe rwork-u p. O n 1/22, are pe at C B C s howe d
the H bd own to 7.1g/d land the W B C c
ou nt 21.3. This re s u lt was printe d on 1/23, whe n he s howe d
the infirm ary nu rs e that he was havingm e le naand was s e nt to the loc
alhos pitalwhe re u ppe r
e nd os c
opy s howe d m u ltiple gas tricu lc
e rs and H P yloriinfe c
tion.
s ane m iawe nt e s s e ntially ignore d forfou rm onths . E ve n afte rac
olonos c
opy
was ad vise d by the ou ts ide hos pitals taff, this re c
om m e nd ation was not followe d .
Patient #3
T his is a38-ye ar-old m an withas thm a, s e izu re s , hype rlipid e m ia, hype rte ns ion and s arc
oidos is. A t
the Fe bru ary 2013c
hronicc
are c
linic
, he was s tarte d on c
hole s te rolm e d ic
ation althou ghhis lipid
profile d id not s e e m to warrant it. H is blood pre s s u re was 132/90and no m e d ic
ation
A pril2014
P onti
ac C orrec ti
onalC enter
P age 11
c
hange s we re m ad e . H is blood pre s s u re m e d ic
ations we re not thos e typic
ally re c
om m e nd e d as firs t
line the rapy.
T he ne xt c
hronic c
are c
linic was on 6/5/13 for hype rte ns ion and hype rlipid e m ia. H is
hype rlipid e m iawas d e e m e d to be we llc
ontrolle d , thou ghthe re we re no ne w labs s inc
e 3/13.
Diabetes
ord s ofpatients e nrolle d in the d iabe te s c
linic
. T wo patients we re m iss ing
re le vant labwork at the ir m os t re c
e nt c
hronicc
are visit, bu t othe rwise we fou nd the c
are to be
tim e ly and appropriate . W e d id c
om e ac
ros s an iss u e in one ofthe re c
ord s , patient [redacted],
who had an e le vate d P SA (8.8)in M ay 2013whichhad not be e n ad d re s s e d . W e brou ght this c
as e
to the atte ntion ofthe M e d ic
alD ire c
tor.
General Medicine
ord s of patients e nrolle d in the ge ne ral m e d ic
ine c
linicand fou nd
opportu nities forim prove m e nt in thre e c
as e s d e s c
ribe d be low.
Patient #4
T his is a67-ye ar-old m an with hype rte ns ion, hype rlipid e m iaand B P H who arrive d at P C C on
11/16/11. T he proble m list was las t u pd ate d 2/5/13and d oe s not list c
hronickid ne y d ise as e , thou gh
his GFR has be e n be low 60forthe pas t two ye ars .
In Janu ary 2013, the patient
s P SA was e le vate d at 5.7(u pfrom 3.4 in Ju ly 2011). H e was s e e n
forhis annu alphys ic
ale xam on 2/5/13by the M e d ic
alD ire c
torwho note d this, d id aprostate e xam
and note d m ild te nd e rne s s . H e tre ate d the patient forpre s u m ptive pros tatitis and ord e re d are pe at
P SA in two m onths . T he labwas ne ve rd one .
O n 3/27/13, the patient was s e e n forge ne ralm e d ic
ine and hype rte ns ion c
linic
s . T he note s are brief
with m inim al phys ic
al e xam s . Labs we re d rawn on 3/4 and re s u lte d on 3/5, bu t the provide r
e vid e ntly d id not have the m , as the labs we re liste d as pe nd ing. T he provid e r d e c
ide d that the
patient
s B P H was we llc
ontrolle d , althou ghthe re was no historic
alinform ation to s u pport this
c
onc
lu s ion.
Opinion:T he risingP SA in this A fric
an A m e ric
an m an ne e d s follow u pgive n the inc
re as e d risk
forpros tate c
anc
e rin this popu lation.
Patient #5
T his is a67-ye ar-old m an withc
oronary arte ry d ise as e , hype rte ns ion, ankylos ings pond ylitis and
C K D . H is proble m list was las t u pd ate d in 2009. H e is pre s c
ribe d Ind oc
in 50 m gtwic
e ad ay
rou tine ly d e s pite s tage 4kid ne y d ise as e withc
re atinine of2.6and GFR of24.
Opinion:T his patient s hou ld not be on rou tine N SA ID s give n his ad vanc
e d kid ne y d ise as e .
A pril2014
P onti
ac C orrec ti
onalC enter
P age 12
Patient #6
T his is a67-ye ar-old m an withd iabe te s whos e proble m list has not be e n u pd ate d s inc
e 2009. H e
has be e n s e e n approxim ate ly e ve ry fou rm onths in c
hronicc
are c
linicove rthe pas t ye arwithlabs
d rawn tim e ly priorto e ac
hvisit.
O n 5/6/13, the patient had an e le vate d P SA at 8.8ng/m l. T his was u pfrom 7.4ng/m lin 2011. T he
labre s u lt was not s igne d , norhas it be e n ad d re s s e d .
HIV Infection/AIDS
W e re viewe d re c
ord s of fou r patients e nrolle d in the H IV c
linic(25% ). T wo patients had
inte rru ptions in the irH IV m e d ic
ations and one was ove rd u e forac
linicvisit.
Patient #7
T his is a 43-ye ar-old with H IV infe c
tion who trans fe rre d to P C C in A pril 2013. T he re is no
proble m list in the c
hart. H e had be e n s e e n in ID te le m e d ic
ine c
linicpriorto his trans fe r(Fe bru ary
2013), at whic
htim e he was note d to be los ingwe ight. H e was 177pou nd s at this visit as c
om pare d
with 196 pou nd s at the visit in N ove m be r 2012. H is H IV d ise as e was u nd e r good c
ontrolon
c
om ple ra, and the c
ons u ltant opine d that the we ight los s was pe rhaps d u e to the patient
s m e ntal
illne s s . T he s pe c
ialist wante d to s e e him bac
k in thre e m onths , bu t he was not s e e n again u ntil
Se pte m be r.
O n 5/5/13, he was s e e n by the M e d ic
alD ire c
torford e c
re as e d appe tite . H is we ight was 162pou nd s ,
ye t the M D note d no obviou s we ight los s and ord e re d m onthly we ight c
he c
ks x 3. Labs d rawn
on 5/7 we re notable for ablood glu c
os e of48 m g/d l, C D 4 c
ou nt of592 and u nd e te c
table viral
load .
O n 5/16, he s aw the P A forhis H IV m e d ic
ation re filland re qu e s te d an e xtraplate d u e to we ight
los s . H is we ight was 171pou nd s . T he P A d e nied his re qu e s t fore xtrafood .
O n 5/21, ID te le m e d ic
ine was c
anc
kd own.
O n 7/18, the patient s aw the P A forre ne walofhis ibu profe n. T he P A note d hyponatre m iaof128
on re c
e nt labs . H e ord e re d 1lite rofIV flu id s followe d by ad os e ofLas ix the n are pe at blood te st
in two we e ks . T his was ne ve rd one .
titione rforwe ight los s . H is we ight was 166pou nd s . She re viewe d
the c
hart and re alize d he had los t 30# ove rthe pas t ye ar and ord ere d ahighprote in highc
alorie
d iet.
O ve rthe ne xt s e ve n m onths , the patient re gaine d the 30pou nd s .
O n 9/16, he was s e e n by te le m e d ic
ine . Labs we re not d one priorto the visit. H is we ight at the tim e
was 157 pou nd s . T he patient told the d oc
tor at this visit that he d id not get his H IV m e d ic
ations
from M ay 8to Ju ne 6. R e view ofthe M A R s hows that the patient was d ispe ns e d 30table ts on 4/20,
none in M ay, the n be gan nu rs e -ad m iniste re d m e d ic
ation on 6/6. T he re were fou r
A pril2014
P onti
ac C orrec ti
onalC enter
P age 13
blanks on the M A R for the re m aind e r of Ju ne . A thre e -m onth follow u p with labs prior was
re qu e s te d . T hre e d ays late r, the patient
s we ight was d oc
u m e nte d as 182pou nd s at s ic
kc
all, thu s
s u gge s tingas u bs tantiald isc
re panc
y be twe e n the s c
ale in the te le m e d ic
ine room and the s c
ale in
the c
e llhou s e c
linic
.
Opinion: It appe ars that this patient d oe s re qu ire e xtrac
alories to m aintain his we ight. Sc
ale s
s hou ld be c
alibrate d re gu larly to ins u re ac
c
u rac
y. T he re was an avoidable inte rru ption in this
patient
s H IV m e d ic
ation.
Patient #8
tion and ahistory ofK apos is arc
om a. H e has be e n s e e n
by ID te le m e d ic
ine approxim ate ly e ve ry thre e m onths withone d e lay be twe e n the N ove m be r2013
and M arc
h2014visits . Labs are d one approxim ate ly 3-4m onths priorto ID visits and he has be e n
s u ppre s s e d withgood C D 4c
ou nts forat le as t the pas t ye ar.
M A R s s how that his m e d ic
ation has be e n d ispe ns e d tim e ly withthe e xc
e ption ofO c
tobe r 2013
whe n the re is no d oc
u m e ntation that one ofthe fou rd ru gs was d ispe ns e d . O n anothe roc
c
as ion in
N ove m be r, he re porte d to the R N d u ringm e d ic
ation pas s that he m ove d from one c
e llhou s e to
anothe rand had be e n ou t ofm e d ic
ation fortwo d ays , as his m e d ic
ations we re in his prope rty. T he
R N re porte d this to the Lt. who s tate d , H e wou ld hand le it.T he re is no follow-u pnote to ve rify
whe n the patient got his m e d ic
ations bac
k.
Opinion: T he re appe ars to have be e n s om e d isru ptions in this patient
s m e d ic
ation c
ontinu ity.
Patient #9
T his is a25-ye ar-old trans ge nd e rm an withas thm aand H IV whos e c
are has be e n c
om plic
ate d by
his nonc
om plianc
e . H e was s e e n rou ghly e ve ry thre e m onths throu ghou t 2013. T he re we re no ID
note s in 2014as ofthe d ate ofou rre view (4/15). T he patient has re pe ate d ly e xpre s s e d the be lief
that God /Je s u s willtake c
are ofhim /he rand the re fore willnot take m e d ic
ations . T he ID c
ons u ltant
has re pe ate d ly re qu e s te d that the patient be re fe rre d to m e ntalhe althforhis u ns table ps yc
hiatric
s tate with d e lu s ional and m agic
al thinking. O ne s u c
h re qu e s t oc
c
u rre d at ID te le m e d ic
ine on
5/7/13, and the nu rs e d oc
u m e nte d the re fe rral. T he patient s aw m e ntalhe alththe ne xt d ay bu t the re
is no m e ntion of the iss u e . T he m e ntalhe alth provide r note d that the patient had no m ood or
ps yc
hotics ym ptom s and that s he wou ld s e e him again in s ix we e ks .
T he patient was pre viou s ly we llc
ontrolle d on m e d ic
ations withu nd e te c
table viralload and good
C D 4c
ou nt. A fte rs toppingthe rapy, his viralload was m os t re c
e ntly m e as u re d at ove r20K and his
C D 4c
ou nt has d roppe d to 282(from 450whe n his viralload was u nd e te c
table ).
Followingthe 8/20ID visit, the ps yc
hiatrist d id ad d re s s his H IV m e d ic
ation nonc
om plianc
e with
the patient, s pe c
ific
ally e xploringhis re ligios ity as it pe rtains to his nonc
om plianc
e , on s e ve ral
oc
c
as ions . E ve ntu ally he was re fe rre d to the T R C (tre atm e nt re view c
om m itte e ) to d e c
ide on
forc
e d m e d ic
ations , bu t no ve rd ic
t has be e n re tu rne d in ne arly s ix m onths . T his c
as e was d isc
u ssed
withthe ps yc
hiatrist, who ac
knowle d ge d the d e lay and s tate d that he wou ld atte m pt to e xpe d ite
this c
as e
A pril2014
P onti
ac C orrec ti
onalC enter
P age 14
Opinion: T his c
halle ngingpatient d oe s not appe arto be c
apable ofm e d ic
ald e c
ision-m aking.
Patient #10
T his is a56-ye ar-old m an withas thm a, hype rte ns ion and H IV infe c
tion whic
hwas d iagnos e d in
the 1980s and has ne ve r progre s s e d . H e is A R T nave . H e was s e e n in H IV te le m e d ic
ine c
linic
rou ghly e ve ry 3-4 m onths u ntilN ove m be r 2013 and labs have be e n d rawn tim e ly prior to the s e
visits , withthe e xc
e ption ofthe D e c
e m be rc
linic
. T he re we re no c
hronicc
are note s in 2014as of
the d ate ofou rvisit (4/15/14).
Opinion: T his patient is ove rd u e foran H IV c
linic
.
Pulmonary Clinic
ord s ofpatients withpu lm onary d ise as e s and had c
onc
e rns abou t one c
as e
d esc
ribe d be low.
Patient #11
T his is a38-ye ar-old m an with as thm a, s e izu re s , hype rlipid e m ia, hype rte ns ion and s arc
oidos is.
A s thm ac
linicwas s c
he d u le d for2/26/13, bu t the patient re fu s e d .
A t the ne xt c
hronicc
are c
linicon 6/5, the patient re ported d aily re s c
u e inhale ru s e . H is pe ak flow
was low at 340. T he nu rs e prac
titione rd isc
u s s e d the prope ru s e ofthe re s c
u e inhale rand d e c
re as e d
his d aily pre d nisone d os e (pre s c
ribe d for s arc
oidos is)from 40 m g/d to 30 m g/d . O the rthan this
inte rve ntion, his s arc
oidos is has not be e n d ire c
tly ad d re s s e d in c
hronicc
are c
linic
. T he pre d nisone
was ord e re d fors ix m onths bu t ne ve rre ne we d . N one ofthe note s s pe ak to this.
hronicc
are c
linicby the M e d ic
alD ire c
tor. T he as thm aform is ne arly
blank withno s u bje c
tive inform ation and no e xam .
O n 3/13/14, the P A s aw him for c
hronicc
are c
linic
. A s thm awas rate d as m ild and u nd e r good
c
ontrol, thou ghthe pe ak flow was 300and it is not note d how fre qu e ntly he was u s inghis re s c
ue
inhale r.
Opinion:T he natu re of this patient
s pu lm onary d ise as e ne e d s to be c
larified (s arc
oidos is vs .
as thm a), as d oe s his pre d nisone u s e .
Seizure Clinic
W e re viewe d fou rre c
ord s ofpatients e nrolle d in the s e izu re c
linic
. In one c
as e , the patient we nt
withou t his s e izu re m e d ic
ation for fou r d ays u pon his arrivalat P C C . In anothe r c
as e , d e s c
ribe d
be low, apatient
s re porte d s e izu re ac
tivity was s e e m ingly d isc
ou nte d be c
au s e it was not witne s s e d
by he althc
are s taff.
Patient #12
T his is a38-ye ar-old m an with as thm a, s e izu re s , hype rlipid e m ia, hype rte ns ion and s arc
oidos is.
Se izu re c
linicwas s c
he d u le d for3/27/13, bu t was re s c
he d u le d d u e to s c
he d u lingc
onflic
t;it was
ne ve rre s c
he d u le d .
A pril2014
P onti
ac C orrec ti
onalC enter
P age 15
O n 3/5/14, the patient was brou ght to the u rge nt c

are u nit for alle ge d s e izu re as re porte d by
sec
u rity.T he patient re porte d he had as e izu re two d ays e arlieras we llbu t s taffC M T s aid it had
to be witne s s e d .H e was plac
e d on s ic
kc
allforthe ne xt d ay and was s e e n by the P A .
O n 3/13, the P A s aw him forc
hronicc
are c
linic
. T he re c
e nt s e izu re was note d and the m e d ic
ation
le ve ls we re d e s c
ribe d as wnl(within norm allim its )thou ghthe m os t re c
e nt re s u lts we re from a
ye arago.
Opinion:In light ofhis re c
e nt s e izu re ac
tivity, this patient s hou ld have m e d ic
ation le ve ls m e as u re d
and ad ju s te d ifne e d e d .
TB Infection Clinic
T he re we re no patients on T B tre atm e nt at the tim e ofou rvisit.
B os we llP harm ac
e u tic
als , loc
ou nte r
m e d ic
ations for the fac
ility. B os we ll is lic
e ns e d as a W hole s ale D ru gD istribu tor/P harm acy
D istribu tor. T he s e rvic
e is afax and fill s ys te m , whic
h m e ans ne w pre s c
riptions faxe d to the
pharm ac
y by 2:00 p.m . willarrive at the fac
ility the ne xt d ay, and re fillpre s c
riptions faxe d by
10:00a.m . willbe re c
e ive d the ne xt d ay. T he loc
alW algre e ns s tore is the bac
k-u ppharm ac
y for
obtaining m e d ic
ation whic
h is ne e d e d im m e d iate ly and is not available in s toc
k. St. Jam e s
H os pital, loc
ate d in P ontiac
, is u s e d to obtain inje c
table m e d ic
ation whe n ne e d e d im m e d iate ly and
is not available in s toc
k. P atient s pe c
ificpre s c
riptions , s toc
k pre s c
riptions and c
ontrolle d
m e d ic
ations arrive pac
kage d in a30-d ay bu bble pac
k. O ve r-the -c
ou nte rm e d ic
ations are provide d
in bu lk by the bottle , tu be , e tc
. T he m e d ic
ation pre paration/storage are ais s taffe d withtwo fu lltim e pharm ac
y te c
hnic
ians , and B os we llprovid e s ac
ons u ltingpharm ac
ist to c
om e on-s ite onc
ea
m onthto re view pre s c
ription ac
y te c
hnic
ian pe rform anc
e and te c
hniqu e
and to d e stroy ou td ate d orno longe rne e d e d c
ontrolle d m e d ic
ations pu rs u ant to the re qu ire m e nts
ofthe Fe d e ralD ru gA d m inistration (FD A )and D ru gE nforc
e m e nt A ge nc
tion of
the m e d ic
ation pre paration/storage are are ve ale d alarge , c
le an, we ll-lighte d and ge ne rally we llm aintaine d are a. A n inte rview withthe le ad te c
hnic
ian re ve ale d aknowle d ge able ind ivid u alwith
13 ye ars workingas apharm ac
y te c
hnic
ian. Ins pe c
ate d tight ac
c
ou ntingof
c
ontrolle d m e d ic
ations , both s toc
k and re tu rn ite m s , ne e d le s /syringe s , s harps /ins tru m e nts and
m e d ic
tion ofpe rpe tu alinve ntories and c
ou nts ind ic
ate d allwe re c
orre c
t.
A llpre s c
riptions , c
ontrolle d m e d ic
ations , s yringe s , ne e d le s and othe r s harp tools are ord e re d ,
re c
e ive d and inve ntoried by the pharm ac
y te c
hnicians . O nc
e re c
e ive d and c
ou nts ve rified , e ach
ofthe ite m s is ad d e d into the ite m s pe c
ificpe rpe tu alinve ntory. Ite m s plac
e d in bac
k s toc
kare
s tore d within aloc
ke d vau lt ins id e the loc
ke d and re s tric
te d ac
c
e s s s torage room . T he pe rpe tu al
inve ntories forallite m s loc
ate d in the vau lt are ve rified d aily. T he c
ras hc
art inve ntory is ve rified
m onthly orany tim e the plas tics e c
u rity s e alis broke n. T he c
ontrolle d m e d ic
ation bac
k s toc
k
pe rpe tu alinve ntory is ve rified d aily. T he pe rpe tu alinve ntories forc
ontrolle d m e d ic
ation in front
orworkings toc
kis ve rified e ac
hs hift by an on-c
om ingand off-goingnu rs ings taffm e m be r.
A c
c
e s s to the m e d ic
ation s torage room is re s tric
te d to nu rs ingad m inistration, nu rs ings taffand the
pharm ac
y te c
hnic
ians . P harm ac
y te c
hnic
ians are re qu ire d to d raw ke ys to the ir are a at the
A pril2014
P onti
ac C orrec ti
onalC enter
P age 17
16
be ginningofe ac
hs hift and re tu rn the ke ys whe n le avingat the e nd ofthe irs hift. In the e ve nt the y
wou ld le ave ins titu tional grou nd s with the ke ys , the y are c
ontac
te d by arm ory pe rs onne l to
im m e d iate ly re tu rn to the ins titu tion. N u rs ings taffm e m be rs hand offthe ir ke ys be twe e n s hifts .
K e ys to the m e d ic
ation s torage room are re s tric
pharm ac
y te c
hnic
ians . K e ys to the bac
k s toc
k vau lt are re s tric
te d to the H e alth C are U nit
A d m inistrator, D ire c
tor of N u rs ingand the two pharm ac
y te c
hnic
ians . In the abs e nc
e of the
pharm ac
y te c
hnic
ians , e m e rge nc
y proc
e d u re s are in plac
e for nu rs ings taff, withapprovalofthe
d u ty ward e n, to s ign ou t the ke ys , e nte r the vau lt and obtain the ne e d e d ite m s . N u rs ings taff is
re qu ire d to d oc
u m e nt an inc
id e nt re port and s u bm it to the H C U A the re as on fore nte ringthe vau lt.
A s e parate loc
ke d c
abine t is u s e d forthe s torage ofinje c
table m e d ic
ations . A llm e d ic
ations in this
c
abine t are m aintaine d on ape rpetu alinve ntory and inve ntoried d aily. R e frige ratorte m pe ratu re s
are m onitore d and d oc
u m e nte d d aily.
C orre c
tionalM e d ic
alT e c
hnic
ians (C M T ), who c
ou ld be e ithe ralic
e ns e d prac
tic
alnu rs e (LP N )or
an e m e rge nc
y m e d ic
al te c
hnic
ian (E M T ), take K e e p on P e rs on (K O P ) bliste r-pac
ks to the
as s igne d c
e llhou s e and d e live rthe m e d ic
ation at c
e ll-s id e to the appropriate inm ate . D os e -by-d os e
m e d ic
ation is ad m iniste re d by lic
e ns e d m e d ic
al staff. T he fac
ility c
ontinu e s to u s e a pape r
m e d ic
ord (M A R ), and e ac
hd os e ofm e d ic
ation ad m iniste re d orre fu s e d is
note d on the patient s pe c
ificM A R . O bs e rvation of bliste r-pac
k d e live ry by an E M T ind ic
ate d
properide ntific
ation ofthe patients and d e live ry ofthe bliste rpac
k. W he n in c
e llhou s e s , s e c
u rity
s taffonly e s c
orts fe m ale m e d ic
als taff.
Laboratory
Laboratory s e rvic
c
e s m e d ic
alc
ontrac
torprovide s 0.75FT E s phle botom y pos itions to d raw and
pre pare the s am ple s for trans port to U IC . T he ind ivid u alis ons ite M ond ay throu gh Frid ay for
approxim ate ly s ix hou rs e ac
h d ay. R e s u lts are e le c
tronic
k to the fac
ility,
ge ne rally, within 24 hou rs vias e c
u re fax line loc
ald e partm e nt. U IC re ports to
boththe fac
ility and the Illinois D e partm e nt ofP u blicH e althallre portable c
as e s . T he re is ac
u rre nt
C linic
al Laboratory Im prove m e nt A m e nd m e nt (C LIA ) waive r c
e rtific
ate that e xpire s Ju ne 13,
2015, on file . T he re we re no re ports ofany proble m s withthis s e rvic
e.
Unscheduled Offsite Services
T he ite m s we look for are whe the r the u rge nt ne e d for s e rvic
e s m ight have be e n m itigate d and
whe the r appropriate c
ontinu ity was provide d afte r retu rn, inc
lu d ingthe re qu ire d offs ite s e rvic
e
d oc
u m e nts . W e re viewe d fou r re c
ord s and in e ac
h of the m the re we re s ignific
ant proble m s ,
inc
lu d ingm iss ingd oc
u m e ntation, d e lays in obtainingre qu ire d proc
e d u re s , and not perform ingor
provid ingre as ons fornot pe rform ingare c
om m e nd e d s e rvic
e by as pe c
ialist.
Patient #1
T his is a47-ye ar-old who was s tatu s pos t pros the tichip re plac
e m e nt and was als o ide ntified as
havingalu ngm as s . H e arrive d at P ontiacon 1/8/14from D anville . H e was s e e n within ad ay by
the phys ic
ian who followe d him u pwithre gard to his lu ngle s ion. Finally, abiops y was pe rform e d ,
whic
hs howe d m e tas taticle iom yos arc
om a. H e we nt to onc
ology on 2/12, and the y re c
om m e nd e d
aP E T s c
an. T his was re qu e s te d to be d one as soon as pos s ible . It was d one alm os t am onthlate r,
on 3/8. T he patient be gan c
he m othe rapy on 4/11and was s e e n by the phys ic
ian on re tu rn. T he re
we re no note s in the c
hart re gard ingthe onc
ology visit.
Patient #2
T his is a27-ye ar-old withahistory ofim m u ne throm boc
ytope nicpu rpu ra(IT P ). T his patient als o
had ahistory ofright te nd on s u rge ry and was s tatu s post tre atm e nt foran analfiss u re . H e was s e nt
to the hos pitalon 2/1/14for are c
talfistu laand alow white blood c
e llc
ou nt. O n retu rn, he was
plac
e d in the infirm ary, havingbe e n in an infirm ary foralm os t s ix m onths . O n 2/18, he was s e e n
at the U nive rs ity ofIllinois, and it was re c
om m e nd e d that he be followe d by ne u rology. A lthou gh
his white blood c
ou nt has im prove d , as has his plate le t c
ou nt, he has s tillnot ye t s e e n ane u rologist.
Patient #3
T his is a32-ye ar-old withape nic
illin alle rgy whic
hyield s angioe d e m a. O n 2/12/14, he was s e nt
ou t u rge ntly to the e m e rge nc
y room for ad isloc
ate d s hou ld e r. H e was s e e n on retu rn by the
phys ic
ian;howe ve r, the re is no e m e rge nc
y room re port in the c
hart.
Patient #4
T his is a 46-ye ar-old with throm boc
ytope niawho was s e nt ou t on 3/27/14, havingarrive d at
P ontiacon 1/27/14. T his patient d id not re c
e ive ad oc
u m e nte d e valu ation re gard ingthe tu m orin
his m ou thand als o the re was no d isc
harge s u m m ary. A fte rwe re qu e s te d it, it be c
am e available .
Unscheduled Onsite Services

ord s ofpatients who re c
e ive d u ns c
he d u le d ons ite s e rvic
e s within the las t thre e
m onths . In five of 11 re c
ord s we ide ntified proble m s . T he s e proble m s inc
lu d e d m iss ingre c
ord
e ntries , an abs e nc
e of vitals igns be ingpe rform e d at ahype rte ns ion e nc
ou nte r, failu re to e nroll
patients in c
hronicc
are whe n the y have c
hronicillne s s e s , and apatient with H IV d ise as e not
havingthat d ise as e liste d on the proble m list.
Patient #1
hronicproble m s who was s e nt ou t on 2/3/14forright lowe rqu ad rant
pain. H e had be e n at P ontiacapproxim ate ly nine m onths . A lthou ghhe is re c
ord e d as havinggone
ou t on 2/3, we c
ou ld find no note s e ithe r in the progre s s note s or in the c
ons u ltation s e c
tion or
anywhe re e ls e .
Patient #2
T his is a43-ye ar-old withhype rte ns ion and s e e n forhype rte ns ion on 2/4/13. O n 1/30/14, he was
s e e n fore le vate d blood pre s s u re in the c
linic
. It is re porte d that he had not be e n takingm e d ic
ations .
H is blood pre s s u re was 168/102. H e was the n re fe rre d to the phys ic
ian on 2/6and
A pril2014
P onti
ac C orrec ti
onalC enter
P age 18
plac
e d on two anti-hype rte ns ive s . H e was s e e n by anu rs e on follow-u pon 3/6withou t vitals igns
be ingpe rform e d and withou t the patient be inge nrolle d in the c
hronicc
are program .
Patient #3
T his is a 43-ye ar-old whos e re c
ord c
ontaine d no proble m list. H e c
om plaine d of e ar pain in
D ec
e m be r 2012. H e was als o be ingtre ate d for H IV . H e had las t be e n s e e n at the U nive rs ity of
Illinois forhis H IV in N ove m be rof2013. T his patient s hou ld have had his H IV liste d on aproble m
list form .
Patient #4
T his is a22-ye ar-old withasthm awho pre s e nte d on 12/2/13withre s piratory c
om plaints . T he nu rs e
pe rform e d a pe ak flow, whic
h was re porte d as 340, whic
h was d own from what was earlier
d esc
ribe d as ape ak flow of 400. T he nu rs ingnote c
onve ys the im pre s s ion that the nu rs e was
u nhappy withhis attitu d e , as s he d e s c
ribe d the patient as be ingangry. H er as s e s s m e nt ind ic
ate s ,
W he e z e s d e te c
ted le ft lowe rlobe .H e ras s e s s m e nt was , R u le ou t re s piratory d istre s s ,and he r
plan none the le s s was , R e tu rn to c
e ll hou s e and s ign u p for s ic
kc
all. T his note ind ic
ate s an
inad e qu ate history re gard inghis as thm aand partic
u larly his u s e ofthe be taagonist c
aniste r. Ifone
he ars whe e z e s and is ru lingou t re s piratory d istre s s, this s hou ld re qu ire an im m e d iate re fe rralto a
phys ic
ian rathe rthan te llingthe patient to s ign u p for s ic
kc
all. T hre e d ays late r, the patient was
s e e n by the phys ic
ian and as s e s s e d as havingbronc
hitis withbronc
hos pas m s . T he patient als o had
an e le vate d blood pre s s u re and this was als o ad d re ss e d . T he nu rs inge nc
ou nterforthis patient was
c
om ple te ly inad e qu ate and pote ntially c
om prom ise d the patient
s statu s.
Patient #5
T his is a41-ye ar-old withtype 2d iabe te s who pre s e nte d on 12/12/13withan e le vate d blood s u gar.
H e was s e e n by the phys ic
ian on 12/12/13, and the patient had not be e n re c
e ivinghis m e d ic
ine s
foralm os t am onth. T he phys ic
ian re s tarte d bothpills and ins u lin forthe patient. T he proble m with
this patient was that althou ghm e d s had be e n ord e re d fors ix m onths in M arc
h, this patient was off
m e d ic
ine s forfou rm onths and he was not appropriate ly e nrolle d in the c
hronicc
are program .

W e d isc
u s s e d with the s c
he d u le r the proc
e s s throu gh whic
hc
e d u re s are
obtaine d . A fte rac
linic
ian ord e rs ac
ons u ltation oraproc
e d u re , the y are allre viewe d by the C hief
M e d ic
alO ffic
e r, who e ithe r agre e s withthe plan or s u gge s ts c
hange s . O nc
e the C hief M e d ic
al
O ffic
e r approve s allre qu e s ts , the y the n are forward e d to the s c
he d u le r. She ind ic
ate d that s he
plac
e s as ix-m onthhold on allpatients forwhom one ofthe s c
e s is re qu e s te d
s o that the y are not trans fe rre d d u ringthe proc
e s s . T his s e e m s like ave ry re s pons ible proc
e d u re .
E ve ry W e d ne s d ay the C hief M e d ic
al O ffic
e r the n pre s e nts the s e re qu e s ts to the W e xford
u tilization m anage m e nt program . A c
c
ord ingto the s c
he d u le r, abou t 90% are approve d as is and
all of the s e rvic
e s are obtaine d at U nive rs ity of Illinois, e xc
e pt for ne w orthope d ic
s c
as e s ,
gas troe nte rology, ophthalm ology, u rology and M R Is . Ifthe re is as u bs tantiald e lay withone of
the s e appointm e nts , e s pe c
ially foru rge nt c
as e s , s he m ay u s e loc
als ou rc
e s . T he s c
he d u le r is als o
able to retrieve re ports throu ghthe U nive rs ity ofIllinois e le c
tronicre c
ord s ys te m . She d oe s trac
k
tim e line s s , bu t only from the d ate ofthe c
olle gialre view.
A pril2014
P onti
ac C orrec ti
onalC enter
P age 19
ord s ofpatients s c
he d u le d foreithe rc
ons u ltations orproc
e d u re s . W e fou nd in
thre e ofthe s e 10re c
ord s the re was e ithe rad e lay in obtainingan appointm e nt, ad e lay in having
the re qu ire d re ports in the m e d ic
alre c
ord orad e lay in ac
c
e s s to aproc
e d u re.
Patient #1
T his is a50-ye ar-old patient withhe patitis C , iron d e fic
ienc
y ane m ia, B arre tt
s e s ophagitis and
non-s pe c
ificc
olitis. H e was s e nt foran u ppe rGI s c
opingon 12/24/13. It was d e laye d and finally
pe rform e d on 1/3/14. T he re port is in the m e d ic
alre c
ord . A fte r the proc
e d u re , the patient was
m aintaine d in the State ville infirm ary. O n 1/7, the patient was trans fe rre d to P ontiacand plac
e d in
the infirm ary. T he infirm ary plac
e m e nt is bas e d on an ord e r by the nu rs e prac
titione r bu t no
progre s s note . T he patient was finally s e e n thre e d ays late r, on 1/10, by the C M O . W e we re
inform e d that the C M O was gone foram onthon are gu larly s c
he d u le d vac
ation and the re was no
phys ic
ian to fillin d u ringhis abs e nc
e. A c
olonos c
opy was ord e re d forthis patient in m id -Fe bru ary
and as ofye t this s e rvic
e has not be e n provide d .
Patient #2
T his is a 55-ye ar-old with hype rte ns ion, hype rlipide m ia and c
anc
e r of the pros tate . H e was
sc
he d u le d for au rology follow-u p visit on 12/11/13. H e has s u rge ry s c
he d u le d for M ay 2014,
whic
hre qu ire s awork-u p be fore hand . H e was s e e n on 3/19, and bas e d on re c
om m e nd ations by
the u rologist, s e ve ralte s ts we re ord e re d . A t the tim e ofou rvisit, approxim ate ly one m onthlate r,
althou ghthe labte s ts we re ord e re d the re we re no re s u lts in the m e d ic
alre c
ord .
Patient #3
T his is a52-ye ar-old withahistory ofapitu itary tu m orstatu s post s u rge ry, hype rte ns ion, s e izu re
d isord e rand d iabe te s ins ipidu s . T his patient was s c
he d u le d foran e nd oc
rinology visit on 1/17/14.
H e was s e e n by the C M O on 1/28, who reord ere d s e ve rallabte s ts ;howe ve r, the re s u lts we re s till
not in the m e d ic
alre c
ord .
Infirmary Care
T he infirm ary, whic
his on the firs t floorofthe he althc
are u nit, is a10-room , 12-be d u nit staffe d
with at le as t one registe re d nu rs e (R N )24 hou rs ad ay, s e ve n d ays awe e k. Inc
lu d e d in the be d
c
onfigu ration are two ne gative airre s piratory isolation room s and fou rm e ntalhe althc
risis room s .
T he ne gative airisolation room s have bothvisu aland au d ible alarm s to ind ic
ate los s ofne gative air
pre s s u re. W he n in u s e for re s piratory isolation, nu rs ings taff c
onfirm ne gative air pre s s u re e ac
h
s hift. O nly the two re ve rs e flow room s are d ou ble c
e lls , the re st are s ingle .
A t the tim e ofou rvisit, the infirm ary c
e ns u s was 6-9patients , the m ajority ofwhom we re m e ntal
he alth plac
e m e nts . O ne room had be e n s e ale d followingan e xpe c
te d d e ath of apatient with
m e tas taticpanc
re aticc
anc
e r. T he R N in the infirm ary told u s that this is s tand ard proc
e d u re
followingad e ath, and that the room willonly be c
le are d by the loc
alinte rnalaffairs afte r the
au tops y re port has be e n re c
e ive d . T he R N m ay not pronou nc
e d e ath;this m u s t be d one by a
phys ic
ian. Ifthe patient
s d e athwas u ne xpe c
te d (i.e ., no D N R ord e r), the n the am bu lanc
e m u st
c
om e to ru n astripand fax it to the loc
alE D forthe E D phys ic
ian to pronou nc
e.
A pril2014
P onti
ac C orrec ti
onalC enter
P age 20
Se c
u rity s taffis pre s e nt in the infirm ary, and inm ate porte rs pe rform the janitoriald u ties and are
s u pe rvise d by boths e c
u rity and nu rs ings taff. P e rs onalprote c
tive e qu ipm e nt is available as ne e d e d ,
and biohaz ard pu nc
tu re proofc
ontaine rs we re in u s e .
T he infirm ary be d s are in poorc
ond ition and ne e d to be re plac
e d . T he re is only one be d that c
ou ld
be c
ons id e re d to be ahos pitalbe d whic
hallows fore le vatingthe he ad ofthe be d , and the raising
and lowe ringofthe whole be d . T he be d is not e le c
tricbu t hand -c
ranke d and is d iffic
u lt to ope rate .
T he re m ainingbe d s are as olid s te e lfram e withas olid m e tals u rfac
e on whic
hthe m attre s s lays .
T he be d s tand s only approxim ate ly 18 inc
he s off the floor. O f ad d itionalc
onc
e rn are the poor
c
ond ition of the m attre s s e s , whe re the ou ts ide plas ticc
ove r is c
rac
ke d or torn and the u s e of
m attre s s e s with no plas ticc
oating, whic
h prohibits athorou gh c
le aningand s anitizingof the
m attre s s .
T he s ink in the nu rs ing s tation, whic
h is u s e d for hand was hing, will not d rain and le aks
u nd e rne ath.
Su pplies are ord e re d e ve ry two we e ks and are ord ere d by anon-m e d ic
alpe rs on. W e we re told this
pre s e nts c
halle nge s to ord e ringe nou ghofthe right kind ofs u pplies .
T he re we re thre e m e d ic
alpatients ad m itte d to the infirm ary d u ringou r visit. T he two c
hronic
ad m iss ions we re a73-ye ar-old A fric
an-A m e ric
an with te rm inalc
anc
e r of the c
olon and s e ve re
ane m ias e c
ond ary to the c
anc
e r, ad m itte d 2/27/14, and a50-ye ar-old A fric
an-A m e ric
an d iagnos e d
with hype rte ns ion and d e m e ntia s e c
ond ary to m ic
ro-c
e re bral infarc
ts (m inis troke s ) ad m itte d
1/27/14. T he third was a23-hou r ad m it for anos e ble e d . C hart re views re ve ale d no iss u e s with
tim e line s s ofprovide rrou nd s orqu ality ofc
are .
T he patient withc
anc
e rofthe c
olon has s igne d aD o N ot R e s u s c
itate (D N R )ord e rand rou tine ly
re fu s e s pain m e d ic
ation, IV hyd ration and blood infu s ions to tre at the ane m ia. H e has re c
e ive d
ps yc
hiatrice valu ations to as s u re he is c
om pe te nt to m ake d e c
isions to re fu s e re c
om m e nd e d
tre atm e nt. P hys ic
ian and nu rs ing s taff are d oc
u m e nting in the patient m e d ic
al re c
ord m ore
fre qu e ntly than re qu ire d by polic
y. T he patient re qu ire s as s istanc
e withac
tivities ofd aily living
(A D Ls ).
T he 50-ye ar-old patient withthe m inis troke s ne e d s as s istanc
e withwalkingand s om e A D Ls . It
appe ars he wou ld be tters e rve d in anu rs inghom e s e tting. T his patient, too, has be e n e valu ate d by
m e ntalhe alth profe s s ionals . A gain, phys ic
ian and nu rs ings taff are d oc
u m e ntingin the patient
m e d ic
alre c
ord we llbe yond polic
y re qu ire m e nts .
T he re is no nu rs e c
alls ys te m . From the nu rs ings tation, nu rs ings taffd o have line -of-s ight into two
ofthe infirm ary room s . A llothe rpatients wou ld have to s hou t orbe at on the ird oorin ord e rto gain
s om e one
s atte ntion. In the e ve nt apatient we re to be inc
apac
itate d , no staffm e m be rwou ld know
u ntile ithe rthe nu rs e ors e c
u rity s taffwho m ake rand om 30m inu te rou nd s we re to find the patient.
A pril2014
P onti
ac C orrec ti
onalC enter
P age 21
Infection Control
T he H e alth C are U nit A d m inistrator (H C U A ) fu nc
tions as the facility infe c
tion c
ontrolnu rs e .
W he n re qu ire d , s he inte rfac
e s with the C ou nty D e partm e nt of P u blicH e alth and the Illinois
D e partm e nt ofP u blicH e alth(ID P H ). T he H C U A /d e s igne e m onitors , c
om ple te s and s u bm its to
ID P H allre portable c
u ltu re d and
tre ate d . P e r the H C U A , the re is a low oc
c
u rre nc
e of c
u ltu re -prove n M e thicillin re s istant
Staphyloc
oc
c
u s au re u s (M R SA )infe c
tions . H e althc
are u nit nu rs ings taffc
ond u c
t m onthly s afe ty
and s anitation ins pe c
tions in the d ietary d e partm e nt and pe rform pre -as s ignm e nt food hand le r
e xam inations for s taffand inm ate s to work in the d ietary d e partm e nt. A tou rofthe he althc
are
u nit, inc
lu d ingthe infirm ary, ve rified pe rs onalprote c
tive e qu ipm e nt (P P E )available to s taff in
allare as as ne e d e d . A d d itionally, P P E is inc
y re s pons e bags and in the c
e ll
hou s e s ic
kc
allroom s . P u nc
tu re proofc
ontaine rs for the d ispos alofs yringe s /ne e d le s and othe r
s harpobje c
ts are in u s e in allare as ofthe he althc
are u nit as ne e d e d and in the c
e llhou s e s ic
kc
all
room s . T he fac
ility u s e s anationalc
om m e rc
ialwas te d ispos alc
om pany ford ispos ingofm e d ic
al
was te . Ins titu tionals taffis traine d in c
om m u nic
able d ise as e s and blood -borne pathoge ns .
A s s tate d pre viou s ly, inm ate porte rs are was hingthe infirm ary line ns and be d d ingin are s id e ntial
type was hingm ac
hine whic
his loc
ate d in the he althc
are u nit. T he prac
tic
e is ofc
onc
e rn s inc
e it
is d ou btfu l the was hingm ac
hine wate r te m pe ratu re s are hot e nou gh to appropriate ly s anitize
infirm ary line ns . A llinfirm ary line ns and be d d ingm u s t be c
ons id e re d to be c
ontam inate d . T he
re qu ire d lau nd e ringproc
e d u re to s anitize line ns and be d d ingis to was hwithlau nd ry d e te rge nt at
awate rte m pe ratu re ofat le as t 160d e gre e s Fahre nhe it foram inim u m of25m inu te s orwas hwith
lau nd ry d e te rge nt and able ac
h bathofat le as t 100 ppm at awate r te m pe ratu re ofat le as t 140
d e gre e s Fahre nhe it foram inim u m of10 m inu te s . T he hot wate rte m pe ratu re s forthe infirm ary
was hingm ac
hine ne e d to be initially c
he c
ke d and rou tine ly m onitore d to as s u re e ithe r140-d e gre e
wate rte m pe ratu re withable ac
hbathor160-d e gre e wate rte m pe ratu re withno ble ac
hbath. It is
d ou btfu l the c
u rre nt wate r te m pe ratu re is ove r 125-130 d e gre e s . If the appropriate wate r
te m pe ratu re c
annot be attaine d , infirm ary line ns and be d d ing m u s t be lau nd e re d in the
ins titu tionallau nd ry whe re , again, the appropriate wate rte m pe ratu re s m u s t be m aintaine d .
InmatesInterviews
Six ins u lin d e pe nd e nt inm ate s we re inte rviewe d . A ll s ix had be e n d iagnos ed s e veral ye ars
pre viou s ly, and all s ix were knowle d ge able regard ing the ir c
hronicd ise as e . A ll s ix were
anc
e ofthe irhe m oglobin A 1cblood le ve l. Five ofthe s ix kne w
the re su lts ofthe irm ost re c
e nt he m oglobin A 1cblood le ve l. A lls ix re ported be inge valu ated by the
phys ic
ian e ve ry 3-4m onths and havingthe ability to perform blood glu c
os e m onitoringpriorto the
ad m inistration ofins u lin. In re spons e to qu e stioning, alls ix s tated that, in ge ne ral, s ec
u rity s taffwas
aware the y were ins u lin d e pe nd e nt d iabe tic
s and we re s e ns itive to the m e d ic
aliss u e s that c
reated .
A lls ix we re ofthe opinion that the nu rs ings taffand , partic
u larly, c
e ll-hou s e C M T s try as be st the y
c
an within the e nvironm e nt to take good c
are ofthe m and to look ou t forthe m . A llwe re ofthe
opinion the phys ic
ian re spons ible forthe ird iabe ticc
are d oe s
A pril2014
P onti
ac C orrec ti
onalC enter
P age 22
agood job;howe ve r, the y we re allope nly c

ritic
alofthe phys ic
ian as s istant, in te rm s ofattitu d e
and c
om pe te nc
e.
It was re porte d bre akfas t is s e rve d be twe e n 6:00a.m . and 7:30a.m .;lu nc
his s e rve d be twe e n 10:30
a.m . and 11:30a.m . and d inne ris s e rve d be twe e n 4:00p.m . and 5:30p.m . B re akfas t is s e rve d in
the c
e ll, and inm ate s go to the d ininghallforlu nc
hand d inne r. It was re porte d that m orningins u lin
is ad m iniste re d be twe e n 5:00a.m . and 7:00a.m ., and afte rnoon ins u lin be twe e n 3:15p.m . to 3:45
p.m . A llinm ate s s tate d bre akfas t c
ou ld be aproble m forthe m ifthe y we re the firs t to re c
e ive the ir
ins u lin, arou nd 5:00a.m ., and not re c
e ive the irbre akfas t u ntillas t, whic
his arou nd 7:30a.m .
A llfive patients voic
e d the followingiss u e s .
1. V e ry little e d u c
2. D iffic
u lty obtainingm e d ic
ation whe n firs t ord e re d and s om e tim e s withre fills
3. D iffic
u lty re c
e ivings hoe s ord e re d by the phys ic
ian be c
au s e the y are d e nied by the m e d ic
al
ve nd or
4. N o pod iatry c
are
5. N o ons ite d ietic
ian
6. W he n e valu ate d by an offs ite s pe c
u lty ge ttingbac
ialist
ialist
7. Se c
u rity s taffnot followingphys ic
ian ord e rs , i.e ., not allowingplas ticbas ins forfoot s oaks
8. B e ingc
u ffe d from be hind too tightly and fortoo long
9. B re akfas t startingbe twe e n 1:00and 2:00a.m .;lu nc
hs tartingat 9:00a.m .
e ive ins u lin priorto e atingand s om e tim e s afte re ating.
Dental Program
Executive Summary
O n A pril3-4 and 14-16, 2014, ac
om pre he ns ive re view ofthe d e ntalprogram at D ixon C C was
c
om ple te d . Five are as ofthe program we re ad d re s s e d to inc
lu d e :1)inm ate s ac
c
e s s to tim e ly d e ntal
c
are ;2)the qu ality ofc
y ofthe
fac
ility and e qu ipm e nt d e vote d to d e ntalc
are ;and 5)the ove ralld e ntalprogram m anage m e nt. T he
followingobs e rvations and find ings are provide d .
T he c
linicits e lf had thre e c
hairs , e ac
h in ad e d ic
ate d are a. T he c
abine try was old and s howing
we arand c
orros ion. T he re was as e parate room forthe d e ntallaboratory and s te rilization are a. A
s m alloffic
e forthe s taffwas attac
he d to the c
linic
. T he s pac
e and e qu ipm e nt was ad e qu ate .
A m ajorare aofc
onc
e rn re late d to c
om pre he ns ive c
are was provid e d withou t
ac
om pre he ns ive intra and e xtra-oral e xam ination and we ll d e ve lope d tre atm e nt plan. N o
e s s . H ygiene
c
are and prophylaxis we re provide d inc
ons iste ntly and oralhygiene ins tru c
tions we re
A pril2014
P onti
ac C orrec ti
onalC enter
P age 23
not always d oc
u m e nte d . B ite wingorpe riapic
alrad iographs we re not always available to d iagnos e
c
aries . R e s torations we re provide d from the inform ation on apane lips e rad iograph.
onc
e e d from a
d oc
u m e nte d d iagnos is. A d iagnos is orthe re as on fore xtrac
ord e ntry.
In le s s than halfthe re c
ord s was the re as on fore xtrac
tion d oc
u m e nte d .
ons tru c
e ofc
are d e live ry inc
lu d e d in
the c
om pre he ns ive c
are proc
proc
tre atm e nt was ne ve rprovid e d . O ralhygiene ins tru c
u m e nte d . It was alm os t
im pos s ible to d ete rm ine that all fillings and e xtrac
tions we re c
u m e nte d .
A t P ontiacC C , d e ntals ic
kc
allis ac
c
e s s e d throu ghthe inm ate re qu e s t form . A c
om ple x s ys te m
of logs and e xam inations at the u nit ins u re s that u rge nt c
are ne e d s are ad d re s s e d in atim e ly
m anne r.
T he SO A P form at was not be ingu tilize d . T re atm e nt was provide d withlittle inform ation ord etail
pre c
e d ingit. R e c
ord e ntries ofte n d id not inc
lu d e c
linic
al obs e rvations or d iagnos is to ju s tify
tre atm e nt.
M e d ic
alc
au tions and c
ord and re d
flagge d to bring the m to the im m e d iate atte ntion of the provide r. T he d e ntal re c
ord was
m aintaine d in the d e ntalc
linic
, s e parate from the m e d ic
alre c
ord . A n ac
c
u rate and thorou ghhe alth
history be c
om e s e s pe c
ially im portant. D oc
u m e ntation in the he althhistory s e c
tion ofthe d e ntal
re c
ord ofinm ate s on antic
oagu lant the rapy was ve ry inc
ons iste nt and s e ld om re d flagge d . B lood
pre s s u re s s hou ld , at the le as t, be take n on patients withahistory ofhype rte ns ion. W he n as ke d , the
c
linic
ians ind ic
A tray ofbu lk, u nbagge d ins tru m e nts was be ingu s e d one at atim e from one ofthe c
abine ts . T he s e
s hou ld be bagge d ind ivid u ally orin kits . T he re was no biohaz ard labe lpos te d in the s te rilization
are a. Safe ty glas s e s we re not always worn by patients . A rad iation haz ard warnings ign was not
poste d in the x-ray are a.
T he d e ntalprogram was involve d in the C Q I proc
es s and was gathe ringd atato e valu ate R e fu s al
forT re atm e ntrate s and re as ons why. P roc
e d u re s we re be ingd e ve lope d to ad d re s s this proble m .
T he d e ntalprogram s hou ld vigorou s ly u tilize the C Q I proc
e s s to ad d re s s the we akne s s e s re ve ale d
in this re view.

P ontiacC C has ad e ntals taffofone fu ll-tim e d e ntist, one 20-hou rpart-tim e d e ntist, two fu ll-tim e
as s istants and afu ll-tim e hygienist. T his s hou ld be ad e qu ate to provide m e aningfu ld e ntals e rvic
es
forP ontiac
s 2000inm ate s .
A pril2014
P onti
ac C orrec ti
onalC enter
P age 24
C P R trainingis c
e s s ary lic
forthe d e ntists .

T he c
linicc
ons ists ofthre e c
hairs and u nits , one fore ac
hd e ntist and on forthe hygienist. T wo of
the d e ntalu nits are five ye ars old orle s s and in good re pair. T he hygienists c
hairis ve ry old , worn
and in poorre pair. It is be ingre plac
e d at this tim e . T he x-ray u nit is in good re pairand works we ll.
T he au toc
lave is rathe r ne w and fu nc
tions we ll. The ins tru m e ntation is ad e qu ate in qu antity and
qu ality. T he hand piec
e s are old bu t we llm aintaine d and re paire d whe n ne c
e s s ary. T he c
abine try
is rathe rold and s howingwe arand c
orros ion, bu t is fu nc
tionally O K . T his d oe s m ake d isinfe c
tion
of c
abine t s u rfac
e s m ore d iffic
u lt. T he oral s u rge on u s e s apne u m atichand piec
e , s o a large
c
ylind e r of nitroge n is in the c
linic
. It take s u p qu ite abit ofs pac
e in the hygiene are a, bu t the
hygienist works withou t an as s istant.
T he c
linicits e lfc
ons iste d ofthre e c
arou nd e ac
hu nit is ac
c
e ptable . P rovide r and as s istant have ad e qu ate room to work, and none of
the c
hairs inte rfe re with e ac
h othe r. T he re was as e parate s te rilization and laboratory room of
ad e qu ate s ize . It had as m allbu t ad e qu ate work s u rfac
c
om m od ate proper
infe c
tion c
ontroland s te rilization. Laboratory e qu ipm e nt was in as e parate c
orne rofthe room . T he
s taffhad as e parate room foroffic
e s pac
e . It was s m alland c
ram pe d and whe re the d e ntalre c
ord s
we re m aintaine d .
Recommendations: N one . T he c
tion to m e e t the ne e d s ofthe
inm ate popu lation at P ontiacC C .

hniqu e s and proc
e d isinfe c
tion was
tants we re be ing
u s e d . P rote c
tive c
ove rs we re u tilize d whe ne ve rpos s ible .
abine ts re ve als that m os t we re properly bagge d and
s te rilize d . T he re was atray ofalarge s tac
k ofwhat I was told we re s te rilize d ins tru m e nts that we re
u nbagge d . T he y we re be ingre m ove d from the tray one at atim e for u s e in patient c
are . A ll
ins tru m e nts s hou ld be bagge d and s te rilize d . A llhand piec
le an m e t
ac
c
e ptable s tand ard s .
tion is always ne c
e s s ary, forpatient and provid e r. I als o obs e rve d that
no warnings ign was pos te d whe re x-rays we re be ingtake n to warn ofrad iation haz ard s .
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P onti
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onalC enter
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I looke d bac
k two ye ars and fou nd the s te rilization logs to be in plac
au toc
lavingwas ac
c
u m e nte d . T he y u tilize the A tte st s ys te m withthe
inc
u bator in the s te rilization are a. N o ne gative re s u lts we re obtaine d . I d id obs e rve that no
biohaz ard warnings ign was pos te d in the s te rilization are a.
Recommendations:
1. T hat allins tru m e nts be bagge d be fore s te rilization and not m aintaine d loos e and in bu lk.
4. A warnings ign be poste d in the x-ray are ato warn pre gnant fe m ale s ofrad iation haz ard s .
Comprehensive Care
tive tre atm e nt c
are proc
eed
from athorou gh, we lld oc
u m e nte d intraand e xtra-orale xam ination and awe lld e ve lope d tre atm e nt
plan, to inc
lu d e all ne c
e s s ary d iagnos ticx-rays . A re view of 10 re c
ord s re ve ale d that no
c
om pre he ns ive e xam ination was pe rform e d and no tre atm e nt plans d e ve lope d . N o e xam ination of
s oft tiss u e s or pe riod ontal as s e s s m e nt was part of the tre atm e nt proc
e s s . H ygiene c
are and
prophylaxis was inc
ons iste nt, provide d in only five ofthe te n patient re c
ord s . A re view of five
ad d itionalre c
ord s re ve ale d that d iagnos ticx-rays for c
aries we re available for only thre e ofthe
five patients . R e s torations we re , in two ofthe five patients , provide d from the inform ation from
the panore x rad iograph. T his rad iographis not d iagnos ticforc
aries . A pe riod ontalas s e s s m e nt was
not d one in any ofthe re c
ord s . Fu rthe r, oralhygiene ins tru c
u m e nte d in
the d e ntalre c
ess.
Recommendations:
u m e nte d
tre atm e nt plan.
tiss u e s .
3. In allc
aries .
4. H ygiene c
ess.
5. T hat c
e s and d e ntal
prophylaxis.
u m e nte d .
A lthou ghP ontiacC C is not are c
e ption and c
las s ific
ation c
e nte r, I re viewe d the s e re c
ord s to ins u re
the re c
e ption and c
las s ific
ation polic
tive 04.03.102, s e c
tion F.
2, are be ingm e t forthe ID O C .
om plianc
e.
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ac C orrec ti
onalC enter
P age 26
Extractions
e e d s from awe lld oc
u m e nte d
d iagnos is. In only fou r of the te n re c
ord s e xam ine d was ad iagnos is or re ason for e xtrac
tion
inc
lu d e d as part ofthe d e ntalre c
ord e ntry.
Recommendation:
1.
A d iagnos is or are as on forthe e xtrac
tion be inc
ord e ntry.
T his
is
be s t ac
c
ially fors ic
kc
alle ntries .
d e ntal re c
ord inc
e as to why that
s s hou ld proc
ord e d on
ad d re s s e d firs t. In only two the five re c
e ivingre m ovable partial
d e ntu re s we re oralhygiene ins tru c
tions provide d . P e riod ontalas s e s s m e nt was not provide d in any
of the re c
ord s , bu t in two of the five re c
ord s aprophylaxis and /or as c
alingd e brid e m e nt was
provide d . B e c
au s e the re was no c
om pre he ns ive e xam ination orany tre atm e nt plans d e ve lope d and
d oc
u m e nte d in any of the re c
ord s , it is alm os t im pos s ible to as c
e rtain if all ne c
e s s ary c
are ,
inc
lu d ingope rative and /ororals u rge ry tre atm e nt, was c
ation ofre m ovable
partiald e ntu re s .
Recommendations:
1. A c
inc
e e d all
c
are , inc
s.
e s s and that the
c
Dental Sick Call

Inm ate s ac
c
e s s s ic
kc
tc
allfrom astaffm e m be rif
it is pe rc
y. D r. M itc
he llre views allre qu e s t form s at le as t by the following
d ay from c
olle c
tion ofthe form s . H e the n s e e s the inm ate in am e d ic
ale xam ination room in e ac
h
u nit as s oon as pos s ible , le s s than one we e k. H e e xam ine s the inm ate and d e te rm ine s his ne e d . T he
patient is the n s c
he d u le d to c
om e to the d e ntalc
linicas s oon as pos s ible oras ne c
e s s ary. U rge nt
c
are ne e d s are s c
he d u le d the ne xt appointm e nt forthat u nit. M id le ve lprac
titione rs forthe u nits are
als o available d aily to ad d re s s u rge nt c
are c
om plaints . E m e rge nc
ies (s e ve re toothac
he , infe c
tions )
are s e e n the s am e d ay. B e c
au s e ofthe s e gre gation m iss ion ofthe ins titu tion, s e e inginm ate s in the
d e ntalc
linicpre s e nts u niqu e c
halle nge s at P ontiacC C . T he re are s e ve ralu nits and only c
e rtain
u nits c
an be s e e n on s pe c
ificd ays . Ins u ringthat inm ate s withu rge nt c
are ne e d s are s e e n in atim e ly
m anne rpre s e nts are alc
halle nge . T he s e
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ac C orrec ti
onalC enter
P age 27
inm ate s are s e e n and e valu ate d by aqu alified provid e rwithin 24to 48hou rs from the d ate ofthe ir
c
om plaint.
B y polic
y, allinm ate s who s u bm it are qu e s t form are to be s e e n by d e ntals taffwithin 14 d ays .
P ontiacC C was in c
om ple te c
om plianc
e withthis polic
y. Im m e d iate toothac
he s orinfe c
tions c
an
be c
alle d in from any u nit and the inm ate willbe s e e n that s am e d ay orthe ne xt. In none ofthe
d e ntalre c
ord s re viewe d was the SO A P form at be ingu s e d . A s are s u lt, tre atm e nt was u s u ally
provide d withlittle inform ation ord e tailpre c
e d ingit. Sic
kc
allre c
ord e ntries ofte n d o not inc
lu d e
c
linic
alobs e rvations ord iagnos is to ju s tify provid e d tre atm e nt. T he u s e ofthe SO A P form at wou ld
ins u re that awe lld e ve lope d d iagnos is wou ld pre c
e d e alltre atm e nt. A ls o, rou tine c
are was ofte n
provide d in the s e appointm e nts , always withou t ac
om pre he ns ive e xam ination ortre atm e nt plan.
T he P ontiacC C d e ntald e partm e nt ke e ps allre qu e s t form s in the d e ntalre c
ord .
Recommendation:
kc
s
c
hief c
om plaint is re c
ord e d and ad d re s s e d , and a thorou gh foc
d iagnos is pre c
Treatment Provision
D e te rm ine whe the rthe d e ntalc
are is provide d fairly and e qu itably forallinm ate s .
A triage s ys te m is in plac
e that prioritize s tre atm e nt ne e d s . A llinm ate re qu e s t form s are e valu ate d
by the d e ntalprogram by the followingd ay and the irtre atm e nt ne e d s are prioritize d . U rge nt c
are
ne e d s are ad d re s s e d that d ay orthe ne xt. O the rs are s c
he d u le d ac
c
ord ingly orplac
e d on the rou tine
tre atm e nt list. Inm ate s are be ings e e n in atim e ly m anne rand the iriss u e s ad d re s s e d .
Inm ate s c
ontac
tingP ontiacC C s taff, who willthe n c
allthe d e ntalc
s
c
om plaint. T he inm ate is s e e n that d ay for e valu ation. R e qu e s t form c
om plaints from inm ate s
withu rge nt c
are ne e d s (c
om plaint ofpain ors we lling)are s e e n at le as t by the followingworking
d ay. M id -le ve lprac
om plaints . T he y
c
an provid e ove r the c
ou nte r pain m e d ic
ation or c
allm e d ic
al/d e ntals taff if the y fe e l m ore is
ne e d e d .
are are e valu ate d the ne xt workingd ay and plac
ed
s e qu e ntially on awaitinglist forthis c
are . A n intric
ate s ys te m ofs e ve rallogs are m aintaine d to
ke e ptrac
k ofc
are ne e d s and who c
an be s e e n whe n, ac
c
ord ingto the u nit in whic
hthe inm ate is
hou s e d . T he waitinglist forrou tine c
are is approxim ate ly nine m onths .
T he O ffe nd e rO rientation M anu alis we lld e ve lope d ford e ntaland ad d re s s e s c
linichou rs , ac
c
ess
to c
are , type s ofc
are , s c
he d u ling, e m e rge nc
yc
are and d e ntalhygiene c
are .
Recommendations: N one . T he s ys te m is fairand e qu itable . A s intric
ate and c
om ple x as it is, it
s e e m s to work we ll. A llinm ate s withu rge nt c
are ne e d s are s e e n in atim e ly m anne r.
A pril2014
P onti
ac C orrec ti
onalC enter
P age 28

T he P ontiacC C has awe lld e ve lope d and c
om pre he ns ive polic
y and proc
e d u ralm anu ald e ve lope d
by D r. M itc
he llthat ad d re s s e s allthe are as c
onc
e rne d .
Failed Appointments
5.4% . T his is we llwithin an ac
c
e ptable range . The d e ntals taff d o agood job in ins u ringthat
inm ate s m ake it to the irappointm e nts .

B ec
au s e the d e ntalre c
ord is m aintaine d in the d e ntalc
alre c
ord ,
id e ntific
ation ofm e d ic
ally c
om prom ise d patients re lies on as s e s s m e nt by the c
linic
ian and on the
history s e c
tion on the c
ove rofthe d e ntalre c
ord . O fthe 10re c
ord s re viewe d ofinm ate s on antic
oagu lant the rapy, only two we re ad e qu ate ly re d flagge d to c
atc
hthe im m e d iate atte ntion ofthe
provide r. Fou rofthe re c
ord s d id not ind ic
ate that the inm ate was on antic
oagu lant the rapy. Fou r
ofthe re c
ord s ind ic
ate d antic
oagu lant the rapy, bu t the y we re not s u ffic
iently re d flagge d .
linic
ians ind ic
Recommendations:
alhistory s e c
al
c
ialpre c
atc
ofthe provide r.
e s pe c
alproc
e d u re.
Specialists
D r. Fre d e ric
k C raig, orals u rge on, is available on an as ne e d e d bas is, u s u ally onc
e am onth. H e
s e e s five patients pe r visit. D r. C raigis als o u s e d by s e ve ralothe r ID O C ins titu tions for oral
s u rge ry. P athology s e rvic
e s are the s am e as form e d ic
alpathology.
In one ins tanc
e , inm ate [redacted], s u rge ry was pe rform e d from a rad iograph from 2005.
R ad iographs s hou ld be no old e rthan two ye ars .
Recommendations:
1. P e rform allorals u rge ry proc
e d u re s from rad iographs le s s than two ye ars old . A nine -ye arold rad iographis oflittle u s e .
A pril2014
P onti
ac C orrec ti
onalC enter
P age 29
Dental CQI
s to the C Q I c
om m itte e . T he d e ntal
program is c
u rre ntly involve d with a C Q I s tu d y that is e valu ating R e fu s al for T re atm e nt
pe rc
e ntage s and the re as ons why. W iththe c
halle nge s ofs c
he d u lingc
are in ad ete ntion ins titu tion,
havings c
he d u le d inm ate s s how forthe irappointm e nt is c
ritic
al. D r. M itc
he llu nd e rs tand s the C Q I
proc
e s s and its valu e .
Recommendations:
1. E xpand the C Q I proc
e s s to ad d re s s the we akne s s e s ou tline d in this re port.
Mortality Review
T he re we re two d e aths at P C C ove rthe pas t ye ar. O ne patient who d ied ofpanc
re aticc
anc
e rhad
no proble m aticiss u e s id e ntified on c
hart re view. T he othe rc
as e had aproble m aticd e lay in c
are
as d e s c
ribe d be low.
Patient #1
T his patient was a42-ye ar-old m an who d ied ofaglioblas tom am u ltiform e on 4/16/13. T he tu m or
was firs t d iagnos e d in 2009, priorto his inc
arc
e ration. H e u nd e rwe nt e xc
ision in M arc
h2009, and
again in Se pte m be r2010forre c
u rre nc
e . H e was ad m itte d to ID O C in Ju ly 2012. H e had are s taging
M R I in O c
tobe r 2012 whic
h s howe d no re c
u rrenc
e and his m ainte nanc
e c
he m othe rapy was
d isc
ontinu e d .
H is m os t re c
e nt M R I on 2/1/13 s howe d re c
u rre nc
e of alow grad e e nhanc
ingm as s in his le ft
te m porallobe and he was s c
he d u le d forne u ros u rgic
alre fe rralon 4/10/13. H owe ve r, on 4/1/13, he
was fou nd with alte re d c
ons c
iou s ne s s and s troke -like s ym ptom s and was take n to St. Jam e s
hos pital, whe re C T s howe d s ignific
ant e d e m aarou nd the m as s and a1c
m m id line s hift. H e was
trans fe rre d to U IC whe re it was d e c
id e d that the risks of s u rge ry ou twe ighe d the be ne fits . T he
fam ily d e c
id e d to withd raw c
are on 4/15/13and the patient d ied the ne xt d ay.
Opinion:A two-m onth d e lay in the ne u ros u rge ry c
ons u lt is e xc
e s s ive give n the natu re of the
patient
s d iagnos is. A lthou gh his long-te rm s u rvivalwou ld not like ly have be e n m u c
h be tte r, it
s e e m s like ly that the d e lay allowe d fore nou ghtu m orgrowthand as s oc
iate d s we llingto pre c
lu d e
fu rthe rtre atm e nt options forthis patient and the re fore s horte ne d his s u rvival.

A s withothe rfac
ilities , we re viewe d the m inu te s and fou nd that the m inu te s c
ons ist ofre ports of
c
olle c
tions ofd ataon the volu m e ofhe alths e rvic
e ac
tivities . T hrou ghou t the m inu te s , the re was no
d esc
ription ofany e fforts to e ithe ras s e s s the qu ality ofpe rform anc
e northe re fore to im prove the
qu ality ofpe rform anc
e . W e s pe nt tim e withthe H ealthC are A d m inistratorre viewingthe ne e d for
the m inu te s to be e d u c
ational, e s pe c
ially forline s taffwho d o not atte nd the m e e tings. T he y m u s t
inc
lu d e d atac
olle c
tion, analys is of the d atain re lations hip to e xpe c
te d pe rform anc
e and , whe re
ind ic
ate d , bas e d on s u bs tand ard pe rform anc
e , an analys is ofthe c
au s e s forthe
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P onti
ac C orrec ti
onalC enter
P age 30
s u bs tand ard pe rform anc

e as we ll as the d e ve lopm e nt of im prove m e nt strate gies d e s igne d to
m itigate the c
au s e s ofthe s u bs tand ard pe rform anc
e.
A pril2014
P onti
ac C orrec ti
onalC enter
P age 31
Recommendations
Intrasystem Transfers:
1. T he intras ys te m trans fe rproc
e s s m u s t be m od ified in away that provide s ove rs ight and
ins u re s that ide ntified proble m s are in fac
t appropriate ly followe d u p.
1. H IV patients s hou ld be followe d by s ite provide rs in c
hronicc
are c
linic
.
2. P atients s hou ld be s e e n ac
c
ord ingto d e gre e ofd ise as e c
ontrolrathe rthan on an e ve ry fou rm onthbas is.
3. M e d ic
ally c
om ple x patients s hou ld be followe d by the M e d ic
alD ire c
tor, at le as t on a
pe riod icbas is.
4. P roble m lists s hou ld be u pd ate d re gu larly.
5. T he re s hou ld be anu rs e d e d ic
ate d to the c
hronicd ise as e program .
Unscheduled Onsite Services:
1. T he re m u s t be a profe s s ional pe rform anc
e e nhanc
e m e nt program that looks at nu rs ing
re s pons e s to ons ite u ns c
e s and c
re ate s an opportu nity for profe s s ional
pe rform anc
e im prove m e nt.
Unscheduled Offsite Services:
1. T he program m u s t im ple m e nt aproc
e s s u pon apatient
s re tu rn from an u ns c
s e rvic
e s o that ne c
e s s ary d oc
u m e ntation, i.e ., e m e rge nc
y room re ports and d isc
harge
s u m m aries , are tim e ly re trieve d and u tilize d in the prim ary c
are c
linic
ian follow-u pvisit.
1. T he s c
e s m u s t be m anage d in away that s e rvic
e s are obtaine d tim e ly
orthe M e d ic
alD ire c
toris notified s o that he c
an fac
ilitate the s c
he d u ling.
2. U pon re tu rn from s c
e s , a s taff pe rs on m u s t be as s igne d the
re s pons ibility oftim e ly re trievalofthe offs ite s e rvic
e re ports . W he n the s e offs ite s e rvic
e
re ports are available , afollow-u pvisit withthe prim ary c
are c
linician s hou ld be s c
he d u le d
and at that visit the re s hou ld be d oc
Infirmary Care:
1. In afac
ility whe re infirm ary s pac
e is at apre m iu m , s e alingaroom to inve s tigate the
e xpe c
te d d e athofapatient withate rm inald ise as e is u nne c
e s s ary and lim its ac
c
e s s to this
pre c
iou s re s ou rc
e.
2. C ons id e ration s hou ld be give n to c
re atingalte rnative s pac
e form e ntalhe althc
risis be d s .
3. B y lic
e ns u re , R N s m ay pronou nc
e d e ath. To e ngage the s e rvic
e s of the am bu lanc
e
c
om pany to pe rform an E C G to c
onfirm d e ath is an avoidable e xpe ns e whic
h d ive rts a
valu able c
om m u nity re s ou rc
e u nne c
e s s arily.
4. T he re ne e d s to be afu nc
tioningc
allbe lls ys te m in the infirm ary.
A pril2014
P onti
ac C orrec ti
onalC enter
P age 32
CQI:
1. T he C Q I program m u s t be le d by pe ople who have be e n traine d in how to ide ntify
pe rform anc
e that is s u bthre s hold , how to analyz e the c
au s e s for the s u bthre s hold
pe rform anc
e and how to im ple m e nt im prove m e nt s trate gies targe te d to m itigate the c
au s e s
and the n to re s tu d y the pe rform anc
e.
c
olle c
tion.
s trate gies .
A pril2014
P onti
ac C orrec ti
onalC enter
P age 33

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Chronic Disease:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
P atient #11
P atient #12
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
P atient #3
A pril2014
Name
Inmate ID
[redacted]
[redacted]
[redacted]
P onti
ac C orrec ti
onalC enter
P age 34
Logan Correctional Center

(LCC) Report
March 31-April 3, 2014

Ron Shansky, MD
Karen Saylor, MD
Larry Hewitt, RN
Karl Meyer, DDS
Contents
Overview....................................................................................................................................3
Findings .....................................................................................................................................7
C linicSpac
e and Sanitation .....................................................................................................8
R ec
e ption P roc
e s s ing...............................................................................................................8
N u rs ingSic
k C all...................................................................................................................10
P hys ic
ian and P A Sic
k C all....................................................................................................12
W om e n
s H e alth....................................................................................................................19
P harm ac
y/M e d ic
Laboratory .............................................................................................................................21
Sc
e d u re s ............................................................23
Infirm ary C are .......................................................................................................................24
Infe c
tion C ontrol...................................................................................................................26
R e s pons e s to the A ttorne y Le tte r...........................................................................................26
D e ntalP rogram ......................................................................................................................29
A pril2014
L ogan C orrec ti
onalC enter
P age 2
Overview
O n M arc
h31-A pril4, 2014, we visite d the Logan C orre c
tionalC e nte r(LC C )in Logan, Illinois.
T his was ou rfirs t s ite visit to LC C and this re port d e s c
om m e nd ations .
D u ringthis visit, we :
al
als e rvic
e s are a
are s taff
u m e nts
W e thank W ard e n A nge laLoc

ke and he rs taffforthe iras s istanc
e and c
oope ration in
c
ond u c
tingthe re view.
Executive Summary
Logan C orre c
tionalC e nte ris the m ain wom e n
s re c
e ption c
e nte rand the large s t pe rm ane nt fe m ale
fac
ility in ID O C . It has am e ntalhe althm iss ion and a20-be d infirm ary. T he popu lation at the tim e
ofou rvisit was 1997, the ave rage age was 36 and ave rage le ngthofs tay was approxim ate ly 18
m onths .
T he H e althC are U nit is ne w c
ons tru c
tion and opene d in 2005. T he u nit is line arin d e s ign. T he re
is alonghallway witha20-be d infirm ary at one e nd , as e c
u rity s tation in the m id d le and ou tpatient
s e rvic
e s at the othe r e nd . T he u nit was c
le an and we ll-m aintaine d bu t ve ry noisy, partic
u larly
d u ringm e d ic
ation ad m inistration, as inm ate s are pe rm itte d to m ove fre e ly to the he althc
are u nit
to re c
e ive the irm e d ic
ation. A s are s u lt, as ignific
antly large grou pofinm ate s are gathe re d in the
he althc
are u nit at one tim e . T he u nit is s taffe d with lic
e ns e d nu rs ings taff, bothre giste re d and
lic
e ns e d prac
tic
alnu rs e s , 24hou rs ad ay, s e ve n d ays awe e k.
T he fac
ility re c
e ive s 30-50inm ate s pe rwe e k, m os tly from C ook C ou nty Jail. A s is tru e at the othe r
re c
e ption fac
ility we visite d , obtainingm e d ic
al inform ation from C C J is d iffic
u lt d e s pite the
pre s e nc
e ofaW e xford e m ploye e at C ook C ou nty. T he fac
ility was ope ratingthe re c
e ption proc
ess
tim e ly and the re was no bac
klogforthe intake phys ic
als .
O ve rc
rowd ingis as ignific
ant iss u e at this fac
ility. For e xam ple , afte r the re c
e ption proc
e s s has
be e n c
om ple te d , inm ate s m ay s tay in the R & C are afor 30 d ays or m ore d u e to lac
k of be d
availability. T he gym is als o be ingu s e d as ahou s ingu nit;c
u rre ntly the re are 20 inm ate s in the
gym bu t the nu m be rhas be e n as highas 70.
T he H e althC are U nit A d m inistrator (H C U A )is ne w to the pos ition bu t not ne w to c
orre c
tional
he althc
are . She pre viou s ly worke d as the D ire c
torofN u rs ing(D O N )at the Linc
oln C orre c
tional
C e nte r, loc
ate d ad jac
e nt to the Logan C orre c
tionalC e nte r, whe n fe m ale s we re hou s e d the re. T he
W ard e n is ve ry s u pportive of the he alth c
are program and , u niqu e ly, the A s s istant W ard e n of
P rogram s is are giste re d nu rs e and aform e rID O C H e althC are U nit A d m inistrator. A t the tim e
A pril2014
L ogan C orrec ti
onalC enter
P age 3
of the ins pe c
tion, the D ire c
tor of N u rs ing(D O N )pos ition was vac
ant, whic
h s ignific
antly and
d ire c
tly im pac
ts on the H C U A
s ability to fu nc
tion as the d e partm e nt he ad ove r the he althc
are
u nit, as s he has to pic
k-u pthe d ay-to d ay d u ties ofthe D O N pos ition. O fpartic
u larc
onc
e rn was
the re porte d ne gative attitu d inaliss u e s of he alth c
are s taff toward inm ate s , partic
u larly fe m ale
inm ate s .
T he M e d ic
alD ire c
toris c
ons c
ientiou s and d e d ic
ate d , his note s are thorou ghand le gible , and his
m e d ic
ald e c
ision m akingis s olid . H e atte m pts to follow his patients c
are fu lly and he d oc
u m e nts
his e nc
ou nte rs thorou ghly. T he re is are als e ns e from talkingwiths taffand re viewingre c
ord s that
he is fu lly inve s te d in the ou tc
om e s of his patients . H e has not be e n pe rform ingthe c
linic
al
ove rs ight d u ties , partic
u larly forthe nu rs e prac
titione rs orthe othe rphys ic
ian.
P rovid e rs taffingc
ons ists ofone M e d ic
alD ire c
tor, one s taffphys ic
ian, two N P s and one P A ;all
are fu ll-tim e pos itions and allpos itions are fille d . The re is als o apart-tim e O B /GY N who provide s
ons ite c
are 24 hou rs pe r we e k. A ll18 LP N pos itions are fille d , as are 18 of 21 R N pos itions .
P rovid e rs have ac
c
e s s to the inte rne t forthe pu rpos e s ofm e d ic
alre fe re nc
e s bu t c
annot ac
c
e s s lab
d ataorhos pitalre c
ord s online .
T he re c
e ption proc
e s s , althou ghu tilizingawe ll-traine d nu rs e and ac
om pe te nt nu rs e prac
titione r,
has s om e d e ficienc
ies to ove rc
om e . T he firs t are ais that the loc
ation ofthe initialnu rs e intake
sc
re e n is in an are awhe re the noise le ve lis s o gre at that it inte rfe re s withthe nu rs e
s ability to
pe rform the s c
re e n. T he s e c
ond proble m is patients arrive withno m e d ic
alinform ation, partic
u larly
from C ook C ou nty Jailand as are s u lt, inform ation that c
ou ld be s e nt from the irc
u rre nt s ite prior
to trans fe ris not m ad e available at the tim e the proc
e s s be gins . T hrou ghthe nu rs e s c
re e n and the
nu rs e prac
titione r history and phys ic
al, the re we re s om e d e fic
ienc
ies with re gard to ad e qu ate
patient histories . T he re was aproble m with follow u p to ide ntify proble m s in s om e c
as e s and ,
c
ons iste nt withthe c
u rre nt polic
y, u ntim e ly follow u pwithre gard to c
hronicd ise as e s . T he re ne e d s
to be aproc
e s s in plac
e to trac
k and ins u re that tim e ly and appropriate follow u pd oe s in fac
t oc
c
u r.
N u rs ings ic
kc
allis c
ond u c
te d s e ve n d ays awe e k by are giste re d nu rs e on the 7:00a.m . to 3:00
p.m . s hift. A ny s ic
kc
allnot c
om ple te d is pic
ke d -u pby the 3:00p.m . to 11:00p.m . nu rs ings taff,
whic
hc
ou ld be are giste re d nu rs e or lic
e ns e d prac
tic
alnu rs e . Sic
kc
allin the X -hou s e , which
hou s e s re c
e ption and c
las s ific
ation, s e gre gation and m axim u m s e c
u rity inm ate s , is only afac
eto-fac
e triage rathe rthan atru e s ic
kc
alle nc
ou nte r. In re s pons e to an inm ate
s writte n c
om plaint,
anu rs e goe s to the inm ate
sc
e lland d isc
u s s e s the c
om plaint throu ghasolid s te e ld oor. B as e d on
the inm ate
s ve rbal c
om plaint, the nu rs e provid e s tre atm e nt abs e nt any phys ic
al e valu ation.
A d d itionally, d aily we llne s s c
he c
ks are c
ond u c
te d on the 11:00 p.m . to 7:00 a.m . s hift and
we e kly visits by the N u rs e P rac
titione r for allinm ate s hou s e d in the s e gre gation u nit;howe ve r,
ne ithe rthe d aily c
he c
ks northe we e kly visits are d oc
u m e nte d .
M e d ic
ations are obtaine d and provide d throu gh the c
om pre he ns ive he alth c
are c
ontrac
t with
W e xford H e alth Sou rc
e s . T he m e d ic
ation s torage and pre paration are a is m anage d by thre e
pharm ac
y te c
hnic
ians with the le ad te c
hnic
ian having23 ye ars of e xpe rienc
e in c
orre c
tional
pharm ac
y m anage m e nt.
A pril2014
L ogan C orrec ti
onalC enter
P age 4
Laboratory s e rvic
e s are provide d by the U nive rs ity ofIllinois-C hic
ago H os pital(U IC )and the re
we re no re porte d proble m s withthis s e rvic
e . D aily, s pe c
im e ns are trans porte d withre ports faxe d
to the fac
ility, ge ne rally the ne xt d ay. T he re we re no re porte d iss u e s withthis s e rvic
e.
T he infirm ary is a20-be d u nit c
om prise d of15d e s ignate d m e d ic
albe d s , thre e m e ntalhe althc
rise s
c
e lls and two ne gative airpre s s u re re s piratory isolation room s . T he u nit is ge ne rally s taffe d with
are giste re d nu rs e , bu t the re are s hifts whe n alic
e ns e d prac
tic
alnu rs e is the only nu rs e as s igne d to
the u nit. T he nu rs ings tation is c
e ntrally loc
ate d and the re is d ire c
t line -of-s ight into only fou rof
the room s . T he re is no nu rs e c
alls ys te m .
A ll patients are ad m itte d and d isc
harge d by the M e d ic
al D ire c
tor. It was d iffic
u lt to re view
infirm ary m e d ic
alre c
ord s as the file s we re in c
om ple te d isarray withan e xte ns ive am ou nt ofloos e
filingand page s ou t ofc
hronologic
alord e r.
A t the tim e ofthe ins pe c
tion, as pe c
ificnu rs e had not be e n as s igne d the d u ties ofInfe c
tion C ontrol
(IC -R N ), and the H C U A was als o fu lfillingthis re s pons ibility. Ins pe c
tions ofthe he althc
are u nit,
re c
e ption and s e gre gation u nit, as we llas rand om hou s ingu nits and othe rare as ind ic
ate d e m ploye e
pe rs onal prote c
tive e qu ipm e nt (P P E ) was available , and he alth c
are s taff was appropriate ly
d ispos ings harps and d ispos able m e d ic
altools . T he fac
ility is c
ontrac
te d withanationally lic
e ns e d
c
om pany ford ispos alofm e d ic
alwas te .
H e alth c
are u nit (H C U ) as s igne d inm ate s are lau nd e ringinfirm ary be d d ingand line ns in a
re s id e ntials tyle was hingm ac
hine loc
ate d in the infirm ary are a. T his is ofc
onc
e rn, as allinfirm ary
line n and be d d ingm u s t be c
ontam inate d , and the available wate rte m pe ratu re s
in the H C U are not highe nou ghto m e e t the re qu ire m e nts to prope rly s anitize the be d d ing.
T he re is ac
ons id e rable m orale iss u e at this fac
ility whic
happe ars to be ne gative ly im pac
tingthe
qu ality of c
are provid e d . H owe ve r, the H e alth C are A d m inistrator im pre s s e d u s by having
d e ve lope d , prior to ou r visit, alist ofc
ritic
alc
hange s that ne e d to be m ad e within the program ,
inc
lu d ingthe ne e d foras u bs tantialc
hange in s om e ofthe s taff
s attitu d e s toward the irpatients .
W e re viewe d ac
olle c
tion ofc
as e s forward e d to u s from an ou ts id e attorne y and fou nd that virtu ally
allofthe c
onc
e rns e xpre s s e d by the inm ate s we re valid . To the c
re d it ofthe c
u rre nt le ad e rs hip
te am , m any ofthe iss u e s id e ntified in the patient
sc
om plaints had be e n ad d re s s e d by the tim e we
visite d the fac
ility. T he s e c
as e s are inc
lu d e d as as e parate s e c
tion ofthis re port.
W ithre gard to u rge nt/e m e rge nt s e rvic
e s , we fou nd as e riou s proble m withan u rge nt c
are re s pons e
in one c
as e . T he proble m id e ntified was that apatient who had an obs e rve d s e izu re was fou nd at
the tim e ofthe arrivalofthe nu rs e not to be havingas e izu re . T he re was no c
ontac
t withaphys ic
ian
and no e ffort to plac
e the patient in the infirm ary forc
los e robs e rvation. O ne d ay late r, the patient
had anothe rs e izu re and was s e nt to the hos pital. W e als o fou nd inad e qu ate as s e s s m e nts by nu rs e s
whic
hm ay be re late d to attitu d inaliss u e s as oppos e d to the ad e qu ac
y ofthe irtraining.
A pril2014
L ogan C orrec ti
onalC enter
P age 5
W ithre gard to s c
e s , we fou nd s e ve ralproble m s , inclu d ingthe fac
t that whe n
patients re tu rn from the iroffs ite s e rvic
e , the y are not brou ght ne c
e s s arily to the m e d ic
alare aand
the re fore the re view ofthe pape rwork and the trigge ringofthe follow-u p visit d oe s not always
oc
c
u r. T he s e proble m s , in te rm s ofins u ringthe offs ite s e rvic
e pape rwork is available and that the
patient is s e e n in follow u pby aprim ary c
are clinic
ian in atim e ly m anne r, m u s t als o oc
c
u r.
T he c
hronicd ise as e program s u ffe rs from alac
k of organization and ove rs ight. T he re was no
s ys te m in plac
e to trac
k any ofthe im portant ind ic
ators forthe program , and the re was as ignific
ant
bac
klogin c
linicappointm e nts . C om pou nd ingthe bac
klogwas the prac
tic
e ofad d re s s ingonly one
c
hronicd ise as e at e ac
hc
linicvisit. T hou ghthis prac
tic
e is s u pporte d by polic
y whic
hd ic
tate s that
c
e rtain d ise as e s be ad d re s s e d d u ringc
e rtain c
ale nd arm onths , it is not c
ond u c
ive to e ffic
ienc
y and
c
om pre he ns ive patient c
are . P atients s hou ld be s e e n ac
c
ord ingto the ird e gre e ofd ise as e c
ontrol,
i.e ., s ic
ke r, m ore poorly c
ontrolle d patients s hou ld be s e e n m ore fre qu e ntly.
M os t ofthe c
hronicc
linic
s we re as s igne d to one ofthe part-tim e d oc
tors whos e note s are le gible
only to him . H is approac
hto c
hronicd ise as e m anage m e nt c
an be d e s c
ribe d as pas s ive at be s t. T his
d oc
tors e e s c
hronicc
are patients onc
e awe e k and s aid he s e e s apatient e ve ry 10-15m inu te s . T his
rate of s pe e d is not, in ou r opinion, c
om patible with qu ality whe n it c
om e s to c
hronicd ise as e
m anage m e nt.
In prac
tic
e , the m ajority of c
hronicd ise as e m anage m e nt is ac
tu ally provide d by the M e d ic
al
D ire c
tor d u ring s ic
k c
all. T his re s u lts in patients ge tting the c
are the y ne e d , and m ay be
c
ontribu tingto the ac
c
e s s proble m foru rge nt c
are iss u e s .
Staffwe re be ginningto u tilize the O T S s ys te m fortrac
kingthe program , bu t no c
om pre he ns ive
d atawe re available forou rre view. (Ind e e d , O T S is not ac
om pre he ns ive trac
kings ys te m and not
we lls u ite d for the c
hronicd ise as e program , bu t this is as tate wide iss u e .)T he m os t re c
e nt d ata
available was from N ove m be r2013and ind ic
ate d that only as m allfrac
tion ofpatients e nrolle d in
the c
linic
s we re s e e n d u ringthe d e s ignate d c
linicm onths . W e m e t withone ofthe two c
hronic
d ise as e nu rs e s , who c
ou ld prod u c
e no d ata re gard ingthe program in te rm s of tim e line s s or
ou tc
om e s .
It s hou ld be m e ntione d that ou rre view was s ignific
antly ham pe re d by the d isorganize d s tate ofthe
he althre c
ord s , m os t ofwhic
hhad large pile s ofloos e filingwithin the ins id e c
ove r. W e we re told
that this was in antic
ipation ofrollingou t the E M R , whic
hwas to have oc
c
u rre d the M ond ay we
arrive d bu t was pos tpone d . Sic
kc
allre qu e s t form s are not file d in the c
harts , bu t ke pt in afiling
c
abine t in the ad m inistrative are a. T he y are not arrange d by nam e or nu m be r, bu t by d ate ;thu s
s e arc
hingthrou ghthe m forthe pu rpos e s ofou rre view was ne xt to im pos s ible .
T he proble m s d e s c
ribe d he re in notwiths tand ing, this was the firs t ofthe fou rins titu tions that we
had visite d whe re we le ft the ins titu tion s om e what optim istic
, partic
u larly ifac
apable D ire c
torof
N u rs ingis ad d e d to the le ad e rs hipte am .
A pril2014
L ogan C orrec ti
onalC enter
P age 6
Findings
T he re is as trongle ad e rs hip te am now in plac
e at Logan. T he W ard e n is ve ry s u pportive ofthe
he althc
are program and , u niqu e ly, the A s s istant W ard e n ofP rogram s is are giste re d nu rs e and a
form e r ID O C H e alth C are U nit A d m inistrator. The M e d ic
alD ire c
tor is ve ry c
ons c
ientiou s and
hard working. T he H e alth C are U nit A d m inistrator (H C U A ) is c
om pe te nt, e ne rge tic and
d e te rm ine d to im prove the program . T he H C U A is ac
u te ly aware ofnu rs ings taffattitu d inaliss u e s
toward inm ate s .
Position
M e d ic
alD ire c
tor
StaffP hys ic
ian
N u rs e P rac
titione r
D ire c
torofN u rs ing
P hys ic
ian
s A s s t.
C orre c
tions N u rs e I
C orre c
tions N u rs e II
Lic
e ns e d P rac
tic
alN u rs e s
.
P hle botom ist
R ad iology T e c
hnic
ian
P harm ac
y Tec
hnic
ian
P harm ac
y Tec
hnic
ian
StaffA s s istant I
C hiefD e ntist
D e ntist
D e ntalH ygienist
O ptom e try
P hys ic
alT he rapist
P hys ic
Total
A pril2014
Current FTE
1
1
2
1
1
0
1
16
0
5
18
0
1
2
1
0.6
3
0
4
0
0
2
2
1
0.15
0
0
62.21
L ogan C orrec ti
onalC enter
Filled
1
1
2
1
0
0
1
14
0
4
18
0
1
2
1.0
0.6
3
0
4
0
0
2
2
1
0.15
0
0
58.21
Vacant
0
0
0
0
1
0
0
2
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4
State/Cont.
C ontrac
t
C ontrac
t
C ontrac
t
State
State
C ontrac
t
State
State
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
State
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
P age 7

T he he althc
are u nit is ne w c
ons tru c
tion and ope ne d in 2005. T he u nit is c
le an, we lllighte d , we ll
e qu ippe d and we llm aintaine d . T he u nit is line arin d e s ign;that is, alonghallway withan inpatient
infirm ary at one e nd , as e c
u rity s tation in the m id d le and ou tpatient tre atm e nt at the othe re nd . A t
one e nd is ahallway that inc
lu d e s a20-be d infirm ary, anu rs ings tation, am e d ic
ation s torage
room , m e d ic
alre c
ord s and ad m inistrative offic
e s . In the m id d le ofthe hallway is as e c
u rity d e s k,
large m e d ic
ation s torage room , two m e d ic
ation ad m inistration room s and atwo-c
hair d e ntal
c
linic
. A t the othe r e nd of the hallway is anu rs ings tation, thre e e xam ination room s with the
pote ntialforfive , one u rge nt c
are /tre atm e nt room , an optom e try c
linicroom , labroom , x-ray and
variou s offic
e s . T he e xam ination room s we re appropriate ly e qu ippe d .
Inm ate porte rs , u nd e r the s u pe rvision of both s e c
d u ties ;porte rs d o not pe rform or have involve m e nt in any m e d ic
al c
are d e live ry. P orters are
provide d an orientation to the he alth c
are u nit whic
h inc
lu d e s prope r c
le aningand s anitation
proc
e d u re s , blood -borne pathoge n trainingand c
om m u nic
ate d ,
the y are provide d pe rs onalprote c
tive e qu ipm e nt. B od ily flu id c
le an u p wou ld be s u pe rvise d by
nu rs ings taff. P orte rs are re s pons ible forlau nd e ringinfirm ary line ns . T his is ofc
onc
e rn, in that all
infirm ary line ns m u s t be c
ons ide re d to be c
ontam inate d and , as a re s u lt, m u s t be lau nd e re d
appropriate ly. T he re qu ire d lau nd e ringproc
e d u re to s anitize line ns is to was h with lau nd ry
d e te rge nt at awaterte m pe ratu re ofat le as t 160d egre e s Fahre nhe it foram inim u m of25m inu te s
orwas hwithlau nd ry d e te rge nt and able ac
hbathofat le as t 100ppm at awate rte m pe ratu re ofat
le as t 140 d e gre e s Fahre nhe it for am inim u m of 10 m inu te s . It is d ou btfu lthe he alth c
are u nit
lau nd ry room wate r te m pe ratu re is ove r 125-130d e gre e s and , as are s u lt, s hou ld not be u s e d to
lau nd e r infirm ary line ns . T he waterte m pe ratu re s hou ld be raise d to am inim u m 140d e gre e s and
ble ac
hprovide d or, ifthe u s e ofble ac
his not pe rm itte d , the wate rte m pe ratu re m u s t be raise d to
160 d e gre e s or the ins titu tional lau nd ry m u s t be u s e d . W ate r te m pe ratu re s in the ins titu tional
lau nd ry m u s t be m onitore d and m aintaine d at the re qu ire d te m pe ratu re s .
T he m e d ic
alre c
e ption proc
e s s oc
c
u rs in the re lative ly ne w X -d e s ign bu ild ingin ahou s ingu nit,
whic
hinc
lu d e s re c
e ption be d s and an are athat has be e n c
onve rte d to pe rform the m e d ic
alre c
e ption
proc
e s s . U nfortu nate ly, the nu rs e s c
re e n take s plac
e in a room within the m e d ic
al re c
e ption
hou s ingare athat als o inc
lu d e s s e ve ralm e ntally illinm ate s . T he noise in that hou s ingare ac
le arly
c
au s e d d iffic
u lties forboththe patient to he arthe nu rs e s ittingthre e fe e t away from the patient as
we llas forthe nu rs e to he arthe patient. T his proble m ne e d s to be ad d re s s e d by s om e m e thod ology.
W e obs e rve d the nu rs e s c
re e ns ofpatients ne wly arrive d from C ook C ou nty Jail. T he y arrive d with
no m e d ic
al inform ation. T he re is a W e xford s taff pe rs on who u s u ally s e nd s m e d ic
ation
inform ation a fe w d ays afte r arrival, bu t the m e d ic
ation inform ation is only a list of any
m e d ic
ations that the patient had be e n on at C ook C ou nty Jail rathe r than a list of c
u rre nt
m e d ic
ations at the tim e oftrans fe r. T his totalc
om m u nic
ation bre akd own is d iffic
u lt to u nd e rs tand ,
s inc
e the C ook C ou nty Jailu s e s an e le c
tronicm e d ic
alre c
ord and is c
apable ofprovid ingaproble m
list, alle rgies , c
u rre nt m e d ic
ations as we llas any s c
he d u le d appointm e nts . T he fac
t that this is not
happe ningis c
le arly an ind ic
tm e nt ofe fforts by the s tate to obtain this
A pril2014
L ogan C orrec ti
onalC enter
P age 8
c
ritic
alinform ation. A t am inim u m , the s tate c
ou ld have ac
c
e s s to the c
ou nty
s e le c
tronicre c
ord s
forthe W e xford pe rs on, who c
ou ld ins u re that this inform ation is available and ye t this s tillhas
not oc
c
u rre d . T he nu rs e s c
re e ns te nd to oc
c
u rwithin the firs t 24hou rs and oc
c
as ionally within the
firs t two d ays . T he nu rs e pe rform ingthe s c
re e n was qu ite c
ons c
ientiou s and s e e m e d to d o an
e xc
e lle nt job(we have c
onc
e rns abou t the form s u s e d and the irc
om ple te ne s s ). In ad d ition, we als o
obs e rve d a nu rs e prac
titione r pe rform ing the intake history and phys ic
al. She als o s e e m e d
c
ons c
ientiou s ;howe ve r, the re was no ove rs ight ofhe rprac
tic
e.
e ption re c
ord s ofpatients who arrive d in the m onthofFe bru ary and am ajority
of the s e re c
ord s we re proble m atic
. T he d e ficienc
ies inc
lu d e d inad e qu ate qu e ryingre gard ing
patient histories , inad e qu ate follow u p and d e lays in ac
c
e s s to c
hronicc
are c
linic
s . E xam ple s of
proble m c
as e s follow.
Patient #1
T his is a24-ye ar-old who arrive d on 2/1/14. She had ahistory ofhid rad e nitis ofthe right axillafor
whic
hs he was give n antibiotictre atm e nt. O n 2/11, s he was told to retu rn in thre e d ays bu t s he was
not s e e n u ntilalm os t am onthlate r.
Patient #2
T his is a53-ye ar-old who arrive d on 2/14/14withahistory ofhype rte ns ion and hype rlipid e m ia.
H e r blood pre s s u re on intake was within norm allim its . H e r proble m list inc
lu d e d hype rte ns ion,
hype rlipid e m iaand ahistory ofm e ntalproble m s . She was s e e n in the hype rte ns ion c
linicon 3/24
and he rblood pre s s u re was e le vate d . T he as s e s s m e nt was blood pre s s u re u nc
ontrolle d and s he was
plac
e d on m e d ic
ations . She had aP ap s m e ar on intake bu t the s pe c
im e n was u ns atisfac
tory and
this has ne ve rbe e n followe d u p.
Patient #3
T his patient arrive d on 2/5/14and he rphys ic
ale xam was pe rform e d on 2/13. She was fou nd to be
H IV pos itive . O n 2/18, s he was re fe rre d forahigh-risk appointm e nt at the U nive rs ity ofIllinois.
T he H IV s pe c
ialist re c
om m e nd e d H IV m e d ic
ations and a follow-u p in two we e ks . T his was
be c
au s e he r C D 4 c
ou nt was low and he r viralload was e le vate d . T he re has be e n no follow-u p
s inc
e and we c
ou ld find no ord e rforthe m e d ic
ations .
Patient #4
T his is a24-ye ar-old who arrive d on 2/14/14withahistory ofhe patitis C and no tre atm e nt. She
was to be followe d u pin two we e ks bu t no follow-u phas oc
c
u rre d .
Patient #5
T his patient arrive d on 3/4/14withas e izu re d isord e rand c
os toc
hond ritis. She was s u ppos e d to be
followe d u pin one m onthbu t that has not happe ne d .
Patient #6
T his is a37-ye ar-old who arrive d on2/13/14withahistory ofhype rte ns ion, statu s post lam ine c
tom y
and asthm a. T he re is astam pin the c
hart that states , N o ind ic
ation forasthm atre atm e nt,bu t the
history has no e xplanation ofwhy that is the c
as e and in fac
t the re had be e n a
A pril2014
L ogan C orrec ti
onalC enter
P age 9
pre s c
ription forabe taagonist inhale r. T his patient als o had hype rlipid e m iaand the re has be e n no
follow-u p.
Patient #7
T his is apatient who arrive d on 2/7/14withas thm a. T he re was no ad e qu ate history. T his patient
was re fe rre d to the as thm ac
linicbu t the c
hronicc
linichas ne ve roc
c
u rre d .
Nursing Sick Call

N u rs ings ic
kc
allis c
ond u c
te d s e ve n d ays awe e k.
T o ac
c
e s s s ic
kc
all, an inm ate c
om ple te s as ic
kc
allre qu e s t s lip and d e pos its it d ire c
tly into a
loc
ke d m e d ic
ald ropbox loc
ate d in e ac
hhou s ingare a. N u rs ings tafffrom the 3:00p.m . to 11:00
p.m . s hift c
olle c
ts the s lips from e ac
h d rop box and c
arries the m to the he alth c
are u nit. In the
he althc
are u nit, 11:00p.m . to 7:00a.m . s hift nu rs ings taff, whic
hc
ou ld be are giste re d nu rs e or
lic
e ns e d prac
tic
alnu rs e , is re s pons ible ford ate s tam pingand re viewinge ac
hre qu e s t to d eterm ine
u rge nt ne e d ve rs u s rou tine ne e d . Inm ate s d e te rm ine d to have u rge nt m e d ic
alne e d s are im m e d iate ly
e valu ate d . Inm ate s d e te rm ine d to have rou tine he althc
are ne e d s are plac
e d on the nu rs e s ic
kc
all
sc
he d u le to be e valu ate d within 72hou rs . T he re viewingnu rs e is re s pons ible to note on the re qu e s t
the s c
he d u le d s ic
kc
alld ate and to initialthe re qu e s t. Sic
kc
allre qu e s t s lips are m aintaine d on file
c
hronologic
ally by d ate in afile c
abine t.
Sic
kc
allis c
ond u c
te d on the d ay s hift by are giste re d nu rs e . A t the e nd ofthe s hift, any s ic
kc
all
re m ainingwillbe pe rform e d by nu rs ings taffon the 3:00p.m . to 11:00p.m . s hift whic
hc
ou ld be
are giste re d nu rs e orlic
e ns e d prac
tic
alnu rs e .
O u ts id e the m e d ic
al d e partm e nt, in the X -H ou s e whe re re c
e ption, s e gre gation and m axim u m
sec
u rity inm ate s are hou s e d , s ic
kc
allis c
ond u c
te d . T he s e inm ate s u s e the s am e s ic
kc
allre qu e s t
s lipproc
e s s to ac
c
e s s s ic
kc
allas the ge ne ralpopu lation inm ate s . In re s pons e to the re qu e s t s lip,
nu rs ings taff, e ithe rare giste re d nu rs e orlic
e ns e d prac
tic
alnu rs e , goe s to the inm ate
sc
e lld oorto
d isc
u s s the he alth c
are c
om plaint. N u rs ings taff are re qu ire d to be e s c
orte d by as e c
u rity s taff
m e m be r. A t c
e ll-s id e , the nu rs e c
onve rs e s withthe inm ate throu ghas olid m e tald oore ve n thou gh
sec
u rity s taff, who c
ou ld ope n the d oor, is pre s e nt. A s are s u lt, any m e d ic
alinform ation provide d
by the inm ate is not c
onfid e ntialas othe r ind ivid u als c
an he ar the c
onve rs ation. B as e d on the
c
onve rs ation, the nu rs e e ithe rtre ats the patient from e s tablishe d tre atm e nt protoc
ols orre fe rs the
patient to aprim ary c
are provide r. H and s on e xam inations are not be ingc
ond u c
te d .
P e rID O C polic
y, a$5.00c
o-pay is c
harge d fornon-e m e rge nc
y, s e lf-ge ne rate d s ic
kc
allre qu e s ts.
D aily we llne s s c
he c
ks are c
ond u c
te d by nu rs ings taffon the 11:00p.m . to 7:00a.m . s hift forall
inm ate s in c
onfine m e nt or loc
k-d own statu s. W e e kly rou nd s are c
ond u c
te d by the nu rs e
prac
titione r. N e ithe rthe we llne s s c
he c
ks northe we e kly rou nd s are d oc
u m e nte d in ahe althc
are
u nits e gre gation logorthe inm ate
s m e d ic
alre c
ord . A nyone e nte ringthe s e gre gation u nitis re qu ire d
by s e c
u rity s taffto s ign into the u nit on as e gre gation log. A s are s u lt ofthe s e gre gation u nit log,
the re is d oc
u m e ntation ofnu rs ings taffand the nu rs e prac
titione rbe ingpre s e nt in the u nit, bu t the re
is no d oc
u m e ntation ve rifyingany inm ate c
ontac
t oc
c
u rre d or any he alth c
are c
om plaints we re
ad d re s s e d . A gain, the as s e s s m e nt is pe rform e d throu ghthe c
e lld oord e s pite
A pril2014
L ogan C orrec ti
onalC enter
P age 10
the re be ingaroom in the bu ild ingwhe re the inm ate c

ou ld be take n to have aprivate c
onve rs ation
and , ifne c
e s s ary, pe rform an appropriate e xam ination. O the rwise , the inm ate is trans porte d to the
m e d ic
alu nit foram ore d e taile d as s e s s m e nt and e xam ination.
W iththe c
u rre nt s ic
kc
allproc
e s s , the re are m u ltiple iss u e s as follows .
1. Lic
e ns e d P rac
tic
alN u rs ing(LP N )s taffis re viewingthe s ic
kc
allre qu e s ts , m aybe orm aybe
not pe rform ingan e xam ination, m akingan as s e s s m e nt and the n form u latingaplan, whic
h
c
ou ld be no tre atm e nt or tre atingfrom approve d tre atm e nt protoc
ols or to re fe r to a
provide r. A llofthe s e ac
tions are be yond the e d u c
ope ofprac
tic
e
foran LP N .
2. A c
e ll-s id e e nc
ou nte roc
c
u rs , whic
his re ally ave rbaltriage , rathe rthan ale gitim ate , hand s on s ic
kc
alle nc
ou nte r.
3. B e ing re qu ire d to talk throu gh a s olid m e tal d oor afford s the inm ate /patient no
privac
y/c
onfid e ntiality in e xpre s s inghe rc
om plaint to the nu rs e .
4. N o appropriate as s e s s m e nt and c
orre s pond ingappropriate e xam ination is c
ond u c
te d .
5. Forind ivid u als in c
onfine m e nt, the re is no d oc
u m e ntation ofthe d aily nu rs ingwe llne s s
c
he c
ks orthe we e kly phys ic
ian/nu rs e prac
titione rrou nd s .
6. It is qu e s tionable as to the re as on c
onfine m e nt we llne s s c
he c
ks are pe rform e d on the
11:00p.m . to 7:00a.m . s hift whe n the pos s ibility form e aningfu ld ialogbe twe e n the inm ate
and nu rs e is m inim al.
A t rand om , 10s ic
kc
allre qu e s ts d ate d Janu ary throu ghM arc
h2014and the c
orre s pond inginm ate
m e d ic
alre c
ord we re re viewe d . T he re view pre s e nte d the following.
1.
2.
3.
4.
N ine ofthe 10re qu e s ts we re d ate stam pe d as be ingre c

e ive d by m e d ic
als taff.
Six ofthe 10re qu e s ts we re initiale d by the re viewingm e d ic
als taffm e m be r.
T e n ofthe 10re qu e s ts we re note d withad ate to be s e e n in nu rs ings ic
kc
all.
Fou rofthe 10patients , e ve n thou ghanu rs ings ic
kc
alld ate was note d on the re qu e st, we re
e valu ate d by aprim ary c
are provide r.
5. In thre e ofthe 10re c
ord s , the inm ate
s c
om plaint was not ad d re s s e d d u ringthe s ic
kc
all
e nc
ou nte r.
6. In two ofthe 10 re c
ord s , an LP N c
ond u c
te d the s ic
kc
all, whic
h is be yond the s c
ope of
prac
tic
e forthe LP N .
7. T wo ofthe 10re c
ord s had no d oc
u m e ntation ofany s ic
kc
alle nc
ou nte rorthat the inm ate
d id not re port fors ic
kc
all.
8. T wo of the 10 re c
ord s c
ontaine d a narrative nu rs ing note rathe r than the re qu ire d
Su bje c
tive -O bje c
tive -A s s e s s m e nt-P lan (SO A P )note .
9. In one ofthe 10re c
ord s , the LP N note d as the P lan (P ), $5.00c
o-paywithno tre atm e nt
re c
ord e d . T he patient was late r e valu ate d and appropriate ly tre ate d by the nu rs e
prac
titione r.
10. In one ofthe 10re c
ord s , the LP N d oc
u m e nte d no e valu ation and the re was no SO A P note .
T he patient was late re valu ate d and appropriate ly tre ate d by the phys ic
ian
s as s istant.
11. N one ofthe 10rand om ly s e le c
te d re c
ord s ind ic
ate d any s ic
kc
allc
ond u c
te d by are giste re d
nu rs e .
A pril2014
L ogan C orrec ti
onalC enter
P age 11
Physician and PA Sick Call

ord s e ac
hfrom the nu rs e prac
titione rs . In e ac
hins tanc
e , ou rre c
ord re view
d e m ons trate d appropriate d e c
ision-m akingand ad e qu ate c
olle c
tion of history d ata as we ll as
obje c
tive d ata. T he s e c
linic
ians appe arto be as tre ngthofthe program .

T he c
hronicd ise as e program s u ffe rs from alac
k ofove rs ight and organization. It is not u tilize d as
the foru m for provision ofc
hronicd ise as e m anage m e nt bu t ins te ad s e e m s to be pe rform e d as a
d istrac
te d afte rthou ght.
T he re are two R N s d e d ic
ate d to the c
hronicc
are c
linic
, thou ghthe y d o get pu lle d to othe rtas ks .
T he y have be gu n e nte ringd atainto O T S s inc
e the arrivalofthe c
u rre nt H C U A in D e c
e m be r;thu s ,
that s ys te m was not u s e fu lform iningd atare late d to the c
hronicc
are c
linic
. T he nu rs e s we re s till
m aintainingapape rlogprinte d from an E xc
e ls pre ad s he e t available only on the c
om pu te rs in the ir
offic
e s . It is the d u ty ofthe c
hronicc
are nu rs e to c
om pile lists ofpatients d e gre e ofc
ontrole ac
h
m onthforthe pu rpos e ofC Q I, bu t this was not be ingd one .
A t the tim e ofou rvisit, the re was ave ry large bac
klogin the c
hronicd ise as e program ;only as m all
frac
tion ofpatients e nrolle d in e ac
hc
linicwe re s e e n in agive n m onth. O nly one c
hronicd ise as e
is ad d re s s e d at e ac
hc
linicvisit. T he m ajority ofthe fe w c
hronicc
are form s that we fou nd d u ring
ou rre view we re c
om ple te d by one ofthe part-tim e d oc
tors , whos e note s are c
om ple te ly ille gible
(e xc
e pt to him )and his approac
hto c
hronicd ise as e m anage m e nt c
an be d e s c
ribe d as pas s ive at
be s t. T his d oc
tors e e s c
hronicc
are patients onc
e awe e k and s ays he s e e s apatient e ve ry 10-15
m inu te s d u ringhis 4-6hou rs hifts .
T he m ajority ofc
hronicd ise as e m anage m e nt is ac
tu ally provid e d by the M e d ic
alD ire c
tord u ring
s ic
kc
all. T his re s u lts in patients ge ttingthe c
are the y ne e d , bu t is c
loggingu ps ic
kc
alland m ay
be c
ontribu tingto the ac
c
e s s proble m for u rge nt c
are iss u e s . T he m ajority of c
hronicd ise as e
m anage m e nt s hou ld ins te ad be happe ningd u ringc
hronicc
are c
linic
, and it wou ld m ake s e ns e for
the M e d ic
alD ire c
torto be the prim ary provide rofthis program , give n that he appe ars to be the
one be s t s u ite d by ou re s tim ation.
It was im pos s ible to d ete rm ine how m any patients we re e nrolle d in the c
T he nu m be rofc
linice nrollm e nts was as follows :
C ard iac
D iabe te s (112)
Ge ne ralM e d ic
ine (129)
H IV Infe c
tion/A ID S (28)
Live r/H e patitis C (120)
T B Infe c
tion (0)
A pril2014
L ogan C orrec ti
onalC enter
P age 12
O nly 77of412patients e nrolle d in the hype rte ns ion c

linicwe re s e e n in the N ove m be rc
linic
, the
m os t re c
e nt m onthwithd ataavailable . W e re viewe d s ix c
harts and fou nd laps e s in tim e line s s of
c
hronicc
are c
linic
s in five ofthe re c
ord s , inc
lu d ingone who had not be e n s e e n at allby aprovide r
s inc
e he rarrivalto Logan ove raye arago.
Patient #1
T his is a46-ye ar-old withpoorly c
ontrolle d d iabe te s and hype rte ns ion who has only one c
hronic
c
are form in he rc
hart, whic
his from Se pte m be r2013. It c
ontains ne arly no inform ation. H e rblood
pre s s u re was 134/96at this visit, bu t this was not ad d re s s e d .
She was s e e n at s ic
kc
allon 12/10/13. H e rblood pre s s u re was 146/88, bu t was not ad d re s s e d .
O n 3/10/14, he rblood pre s s u re was 161/103. H e rblood pre s s u re m e d ic
ation was d isc
ontinu e d and
as im ilar m e d ic
ation ord e re d in its plac
e . B lood pre s s u re c
he c
ks we re ord e re d . W e re qu e s te d the
logforre view, bu t we re told the blood pre s s u re logis give n to the patient afte rit is c
om ple te d .
s blood pre s s u re has not be e n ad e qu ate ly m anage d . W hile the patient s hou ld
c
e rtainly re c
e ive ac
opy ofthe log, the m ain pu rpos e ofm onitoringthe blood pre s s u re is forthe
provide rto re view the re ad ings in ord e rto be tte rtre at the patient.
Patient #2
T his is a23-ye ar-old type 1d iabe ticwithhype rtens ion, as thm aand C K D . A t he rbas e line c
linic
on 10/13/13, he r blood pre s s u re was 153/103. B lood pre s s u re c
he c
ks we re ord e re d , bu t
m e d ic
ations we re not ad ju s te d .
O n 3/5/14, s he was s e e n by the R N forc
he s t pain and vom iting. H e rblood pre s s u re was 149/102
and pu ls e was 102. A n E C G was obtaine d and s howe d s inu s rhythm withP V C s . She was ke pt
ove rnight forthe phys ic
ian to s e e in the m orning. T he ne xt d ay, the d oc
tors aw he rforhype rte ns ion
c
linic
. H is note is c
om ple te ly ille gible , s o we as ke d him to re ad it to u s . It m ake s no m e ntion of
the e ve nts ofthe priord ay.
s blood pre s s u re has not be e n m anage d ad e qu ate ly, norwas the e pisod e of
c
he s t pain.
Patient #3
T his is a44-ye ar-old withH IV and hype rte ns ion whos e las t hype rte ns ion c
linicvisit was in Ju ly
2013.
Patient #4
T his is a59-ye ar-old wom an withhype rte ns ion and hype rlipide m ia. She was s e e n in hype rte ns ion
c
linicon 11/27/13, he r firs t provide r visit s inc
e trans fe rringto Logan e ight m onths e arlier. N o
phys ic
ale xam is d oc
u m e nte d ;in fac
t, the re is alm os t nothingd oc
u m e nte d in the note.
Patient #5
A pril2014
L ogan C orrec ti
onalC enter
P age 13
T his is a 39-ye ar-old wom an who arrive d at Logan in M arc

h 2013 with hype rte ns ion and
hypothyroid ism . She has ne ve rbe e n s e e n by aprovid e rat Logan.
Patient #6
T his is a50-ye ar-old fe m ale withahistory ofhype rte ns ion, hype rlipid e m iaand s e izu re s who has
be e n s e nt to the loc
alE D thre e tim e s ove r the pas t ye ar for s ym ptom s of c
he s t he avine s s with
nu m bne s s d own le ft arm and nau s e a. E ac
htim e s he ru le d ou t foran ac
u te c
ard iacs ynd rom e (A C S)
and was re tu rne d to the prison.
A fte rone s u c
hou tingin M arc
h2013, the E D d oc
tors u gge s te d an ou tpatient stre s s te st. T his was
re qu e s te d and d e nied .
Opinion:E xc
lu d ingan ac
u te c
ard iace ve nt is im portant, bu t d oe s not e xc
lu d e the pos s ibility of
u nd e rlyingc
oronary arte ry d ise as e . W e agre e withthe E D phys ic
ian that this patient s hou ld have
as tre s s te s t.
Diabetes
D iabe te s c
linic
s oc
c
u r in Janu ary, M ay and Se pte m be r. Le s s than half (57)of the 112 e nrolle d
patients we re s e e n in Janu ary, 25% ofwhom we re in poorc
ontrol.
Patient #7
T his is a29-ye ar-old type 1 d iabe ticwho arrive d at Logan in M arc
h 2013. She is blind from
d iabe tice ye d ise as e . She als o has C K D , hype rlipid e m iaand bipolar d isord e r. She was s e e n in
d iabe te s c
linicin Se pte m be r and Janu ary. O n 9/21/13, s he was s e e n at D SC for noc
tu rnal
hypoglyc
e m iaand he r ins u lin d os e was d e c
re as e d . Fou rd ays late r, anothe rphys ic
ian s aw he r in
d iabe te s c
linicand inc
re as e d he r ins u lin be c
au s e he r A 1cwas 7.2% . H is note c
ontains m inim al
inform ation, whic
his ne arly im pos s ible to d e c
iphe r. It was c
le arhe d id not re view the c
hart with
re gard to he rre c
e nt hypoglyc
e m ice pisod e .
O n 1/17/14, s he was s e e n in d iabe ticc
linicby s tillanothe rd oc
torwho opine d that s he was in poor
c
ontrolthou ghhe rA 1cwas 7.7% on 12/20/13. N o m e d ic
ation c
Opinion: P rovide rs are not re viewingthe he alth re c
ord to get awe ll-inform e d pic
tu re of the
patient
s d e gre e ofc
ontrol.
Patient #8
T his is a39-ye ar-old withd iabe te s d iagnos e d at he rpre viou s inc
arc
e ration in Fe bru ary 2012. She
arrive d at Logan on 2/11/14. Labs we re d one on ad m iss ion bu t d id not inc
lu d e an A 1c
. T he intake
phys ic
ale xam d oe s not list d iabe te s thou ghs he is e nrolle d in the c
linic
.
Patient #9
T his is a40-ye ar-old wom an withhe patitis C and poorly c
ontrolle d type 1 d iabe te s . T he re was
only one c
hronicc
are c
linicnote in the c
hart whic
h was d ate d 10/5/13;it c
ontaine d alm os t no
inform ation. Labs we re d rawn be fore this visit, bu t d id not inc
lu d e an A 1c
.
A pril2014
L ogan C orrec ti
onalC enter
P age 14
She has be e n s e e n re gu larly in D SC and m e d ic

ations have be e n ad ju s te d . A s of 12/27/13, he r
d iabe te s was poorly c
ontrolle d withan A 1cof9.5% .
Opinion: T his patient has re c
e ive d the m ajority ofhe rc
hronicc
are at D SC rathe rthan at c
hronic
c
are c
linic
.
Patient #10
T his is a46-ye ar-old withpoorly c
ontrolle d d iabe te s and hype rte ns ion who has be e n s e e n onc
e in
c
hronicc
are c
linicin Se pte m be r 2013. T he re we re labs on 9/5 with an A 1cof 10.5% , bu t
m e d ic
ations we re not ad ju s te d norwe re the y e ve n re ne we d . She was the n s e e n on 9/19in D SC by
the M e d ic
alD ire c
tor, who re ne we d he r m e d ic
ations . T he las t tim e he r ins u lin was ad ju s te d was
A u gu s t. H e rm os t re c
e nt A 1cwas in D e c
e m be r and was 10.4%. Labs we re d rawn on 3/4/14bu t
d id not inc
lu d e an A 1c
.
s d iabe te s has not be e n m anage d aggre s s ive ly e nou gh. She is ove rd u e fora
c
hronicc
are appointm e nt.
Patient #11
T his is a23-ye ar-old type 1d iabe ticwithhype rte ns ion, as thm aand C K D who was on an ins u lin
pu m p prior to inc
arc
e ration. She has d iabe ticgas tropare s is withre frac
tory nau s e aand vom iting
forwhic
hs he u nd e rwe nt port plac
e m e nt forfre qu e nt intrave nou s flu id infu s ions . She has not be e n
s e e n in d iabe te s c
hronicc
are c
linicin the pas t ye ar, bu t s he is s e e n ofte n by the M e d ic
alD ire c
tor
who is m anaginghe rd iabe te s at s ic
kc
all. H e rblood glu c
os e le ve ls have be e n e rraticwithfre qu e nt
low re ad ings. H e rA 1cwas 7.5% on 9/12/13, the m ost re c
e nt m e as u re m e nt in the re c
ord as ofA pril
1.
Opinion: T his fragile patient s hou ld be trac
ke d c
los e ly in the c
hronicc
are c
linic
.
General Medicine
A s ofthe d ate ofou rvisit, only 17ofthe 129patients e nrolle d in this c
linichad be e n s e e n in the
priorfou rm onths . T he c
as e be low was typic
al.
Patient #12
T his is a 39-ye ar-old wom an who arrive d at Logan in M arc
h 2013 with hype rte ns ion and
hypothyroid ism . She has ne ve rbe e n s e e n by aprovid e rat Logan. H e rT SH was norm alon 1/3/14.
HIV Infection/AIDS
P atients u s u ally s e lf-c
arry the irH IV m e d ic
ations , whic
hpre s e nts obviou s c
halle nge s to trac
king
c
om plianc
e . In ge ne ral, we fou nd that patients we re s e e n tim e ly in ID te le m e d ic
ine c
linicand that
labs we re d rawn tim e ly prior to the s e appointm e nts . Forthos e patients who are c
om pliant with
m e d ic
ations and whos e d ise as e is u nd e rgood c
ontrol, this works we ll. H owe ve r, as is the c
as e in
othe rID O C fac
ilities , ins titu tion provid e rs are not involve d in trac
kingpatients H IV d ise as e and
s o m e d ic
ation nonc
om plianc
e goe s u nd e te c
te d and u nad d re s s e d u ntilthe ne xt ID visit, whic
his
u s u ally thre e orm ore m onths away. In ad d ition, patients m ay be at risk of
A pril2014
L ogan C orrec ti
onalC enter
P age 15
m e d ic
ation d isc
ontinu ity whe n the y are m ove d to the s e gre gation u nit. T he c
as e be low illu s trate s
the s e proble m s .
Patient #13
T his is a29-ye ar-old wom an withH IV who arrive d at Logan in M arc
h2013on A tripla. O n 5/3/13,
s he re porte d to the nu rs e that s he was not takinghe rm e d ic
ation e ve ry d ay d u e to s ide e ffe c
ts . She
was re fe rre d to the M D . She pre s e nte d again to the nu rs e on 5/5 withthe s am e c
om plaints . She
was finally s e e n by the M D on 5/13.
O n 6/4/13, s he was s e e n by ID te le m e d ic
ine . She re porte d that s he had m iss e d fou r d ays of
m e d ic
ation whe n s he was in s e gre gation be c
au s e the y d id n
t bringit to m e .R e view ofthe M A R
c
onfirm s that the re are s ix blank s pac
e s that c
orre s pond to the tim e pe riod s he d e s c
ribe d .
She was ne xt s e e n by the ID d oc
toron 10/3/13, at whic
htim e s he re porte d that s he had not be e n
takinghe rH IV m e d ic
ation for4-6we e ks , initially blam ings tafffornot bringingit forhe r, bu t on
qu e s tionings tate d that s he d oe s not want to take it in the m orning. R e view ofthe M A R s hows that
alls pac
e s in A u gu s t and Se pte m be rare blank. H e rm os t re c
e nt labs re fle c
te d this;on 9/13/13, he r
viralload was d e te c
table at 522c
opies . T he ID d oc
torhad alongand d e taile d d isc
u s s ionwith
the patient abou t the im portanc
e of c
om plianc
e . T he m e d ic
ation was re s tarte d and m ove d to
e ve ning.
A t the ne xt visit on 2/21/14, s he re porte d 100% c
om plianc
e and labs from 1/3/14re fle c
te d that he r
viral load was again u nd e te c
table and C D 4 was 480 c
e lls . M A R s c
onfirm c
om plianc
e from
O c
tobe rforward .
Opinion: T his patient was not re fe rre d tim e ly to aprovide r whe n s he re porte d s ide e ffe c
ts from
he rH IV m e d ic
ation. T he re was an avoidable inte rru ption in m e d ic
ation c
ontinu ity whe n s he was
hou s e d in s e gre gation. T he re afte r, he rm e d ic
ation nonc
om plianc
e s hou ld have be e n id e ntified and
inte rve ne d u pon had s he be e n followe d on s ite .
Pulmonary Clinic
O nly 30of138e nrolle d patients we re s e e n in the d e s ignate d m onthofFe bru ary. W e re viewe d five
rand om c
harts ofpatients withas thm a. O ne patient had be e n s e e n only onc
e in c
hronicc
are c
linic
in the pas t ye ar, and anothe rpatient had not be e n s e e n at all, bu t m anage d e pisod ic
ally at M D line .
A third patient was d iagnos e d withm ild e rd ise as e than the e vid e nc
e s u gge s te d . T he two re m aining
c
as e s re ve ale d avariety ofiss u e s and are d e s c
ribe d be low.
Patient #14
T his is a31-ye ar-old wom an withas thm a. A t he rintake phys ic
al, the nu rs e prac
titione rs tam pe d
the c
hart withas tam p that re ad no ind ic
ations for asthm atre atm e nt at this tim e . Ifre s piratory
d iffic
u lty re port to H C U fore valu ation.H e rinhale rwas not ord ere d .
O n 7/22/13, s he was s e e n at nu rs e s ic
kc
all for he ad ac
he and re qu e s te d he r inhale r. She was
re fe rre d to the M D ifs hortne s s ofbre athge ts wors e ,bu t not s e e n.
A pril2014
L ogan C orrec ti
onalC enter
P age 16
O n 10/2/13, s he pre s e nte d to nu rs e s ic

kc
allto requ e s t an inhale r and was pu t on M D line for
10/24/13. T he re is no note forthat d ate .
O n 12/18/13, s he was s e e n by R N forc
he s t hu rting, as thm aand c
ou gh.P e ak flows we re low at
300, 325and 350. H e rhe art rate was e le vate d at 120be ats pe rm inu te and he rpu ls e ox was norm al
at 98% . She was c
ou ghingwiths c
attere d whe e z e s . T he c
as e was d isc
u s s e d with(bu t not s e e n by)
the d oc
tor, who ord ere d ne bu lize rtre atm e nts as ne e d e d and re ord e re d he rinhale r.
She was not s e e n again forhe ras thm aas ofthe d ate ofou rvisit. She d oe s not appe arto be e nrolle d
in the c
hronicc
are program .
Opinion:T his patient has not be e n s e e n by aprovid e rforhe ras thm as inc
e s he arrive d at Logan a
ye ar ago. It was inappropriate for the nu rs e prac
titione r to d isc
ou nt he r history of as thm a at
re c
e ption.
Patient #15
T his is a25-ye ar-old wom an withas thm awho re porte d takingan inhale d s te roid and be taagonist
whe n s he e nte re d ID O C in 2011, bu t it appe ars that the s e we re not ord e re d forhe r, as s he was no
longe ron the rapy u pon trans fe rto Linc
oln in 2012norto Logan in M arc
h2013. T he firs t re c
e nt
m e ntion ofas thm awas A u gu s t 2013whe n s he re porte d this to the phys ic
ian. She had no whe e z ing
and s o was not pre s c
ribe d an inhale r.
O n 1/30/14, s he was s e e n withwhe e z ingand got ane bu lize r tre atm e nt and was re fe rre d to the
nu rs e prac
titione r. She was s e e n two we e ks late r, on 2/13/14, by the nu rs e prac
titione rforwhe e z ing
x 1-2 we e ks and re porte d gettingbre athingtre atm e nts e ve ry othe r d ay. T he nu rs e prac
titione r
d esc
ribe d the lu ngs as c
le ar and wrote, U nable to d oc
u m e nt as thm a. N o note s d oc
u m e nting
bre athingtre atm e nts fou nd .She re fe rre d the patient to the as thm ac
linic
.
O n 2/17, s he was s e e n by the R N for s hortne s s of bre ath and whe e z ingand got ane bu lize r
tre atm e nt.
O n 2/18, s he was s e e n on M D line foras thm ae valu ation. H e rpe ak flow was 320and the phys ic
ian
ord ere d an inhale r.
O n 2/19, s he was s e e n forhe rbas e line as thm ac
linicby ad iffe re nt phys ic
ian. H e rpe ak flows were
low at 290, bu t the phys ic
ian d e e m e d he rto be u nd ergood c
ontrolbas e d on no be taagonist u s e. H e
s e e m e d u naware that s he had not be e n pre s c
ribe d an inhale ru ntilthe d ay be fore .
O n 2/28, s he pre s e nte d to H C U for s hortne s s of bre ath and c
he s t tightne s s . H e r vitals we re
abnorm alwith ablood pre s s u re of 138/102 and he art rate of 101. H e r oxyge n s atu ration was
norm alat 94% , bu t pe ak flow was low at 325-350. H e rlu ngs we re d e s c
ribe d as c
le arand s o the
nu rs e s e nt he rbac
k to he ru nit.
O n 3/9, the re is anote from an R N s tating, I/M has be e n c
om ingto H C U on anightly bas is for
as ne e d e d bre athingtre atm e nts . I/M is in no ac
u te d istre s s , no whe e z ing, no s igns ofany
A pril2014
L ogan C orrec ti
onalC enter
P age 17
re s piratory d iffic
u lty, s o s he c
alle d the M e d ic
alD ire c
torand got an ord e rto stopthe ne bu lize r
tre atm e nts .
Opinion:It d oe s not appe ar that this patient has be e n e valu ate d ad e qu ate ly for as thm a. If the
d iagnos is is in qu e s tion, apu lm onary fu nc
tion te s t wou ld be he lpfu l.
Seizure Clinic
O fthe 184patients e nrolle d in s e izu re c
linic
, only 15we re s e e n d u ringthe m os t re c
e nt c
linicin
D ec
e m be r. T he re s e e m s to be as om e what c
avalier attitu d e at this ins titu tion toward tre ating
s e izu re d isord e rs , as the c
as e s be low illu s trate .
Patient #16
T his is a49-ye ar-old fe m ale withas e izu re d isord e rwho arrive d at Logan on 1/22/14. She has not
ye t be e n s e e n in c
hronicc
are c
linicbu t has had no d oc
u m e nte d s e izu re s . H e rD ilantin le ve lwas
the rape u ticat 17.9on 1/27, bu t the phys ic
ian c
hange d he rd os e withou t avisit ore xplanation.
Patient #17
T his is a37-ye ar-old fe m ale withs e izu re d isord e rwho was s e nt to Logan in M arc
h2013 on no
s e izu re m e d ic
ations be c
au s e s he was in he rs e c
ond trim e s te rofpre gnanc
y. H e rc
hart had ahu ge
wad ofloos e filingins id e the front c
ove r d atingbac
k to M ay of2013. She has not be e n s e e n in
s e izu re c
linics inc
e he rarrival.
She has had ve ry fre qu e nt re porte d bre akthrou ghs e izu re s withm u ltiple c
od e 3s c
alle d to he ru nit.
R are ly has ac
od e 3re s u lte d in afollow-u pappointm e nt withaprovide rore ve n trans portation to
the he althc
are u nit. It is c
le ar from c
hart d oc
u m e ntation that the re is s trongs u s pic
ion that the s e
are not tru ly s e izu re s , d e s pite the fac
t that s he has s e e n ane u rologist who re c
om m e nd e d s he be
tre ate d withanti-s e izu re m e d ic
ation. She had athe rape u ticm e d ic
ation le ve lin N ove m be r 2013,
bu t it has not be e n c
he c
ke d s inc
e.
T he las t tim e s he was s e e n by aprovid e r for s e izu re s was in the be ginningofN ove m be r whe n
s he was ad m itte d to the infirm ary withu nc
ontrolle d s e izu re s . M e d ic
ations we re ad ju s te d at that
tim e .
Opinion:T he natu re ofthis patient
sc
ond ition has not be e n ad e qu ate ly c
larified . Ifit is d e te rm ine d
that s he has as e izu re d isord e r, s he s hou ld be e nrolle d and followe d in the c
Ifnot, the n tre atm e nt withantic
onvu ls ant m e d ic
ation s hou ld be re c
ons id e re d .
Patient #18
T his is a49-ye ar-old wom an withahistory ofbrain s u rge ry re s u ltingin s e izu re s , who arrive d at
Logan on 4/10/13. O n 4/11, the nu rs e prac
titione rs aw he r forabas e line s e izu re c
linicvisit. T he
patient re porte d he rlas t s e izu re was abou t one m onthago. C ontrolwas rate d as good .
O n 8/26, he r D ilantin le ve lwas u nd e te c
table . T he re we re no ne w ord e rs and no visit with the
patient. T he m e d ic
ation is s e lf-c
arry and M A R s s how that it was d ispe ns e d to he rm onthly e xc
e pt
forO c
tobe r2013, whic
his blank.
A pril2014
L ogan C orrec ti
onalC enter
P age 18
O n 10/8, the le ve lwas s u bthe rape u ticat 4.7. T he P A wrote on the labthat s he was we ll
c
ontrolle d on herc
u rre nt d os e withno s e izu re s x 6m onths , bu t the re is no e nc
ou nte rin the c
hart.
T he ne xt visit was 12/26, whe n the phys ic
ian noted no s e izu re s s inc
e he r las t visit. T he D ilantin
le ve lon 12/13was 11.7;this was s igne d by the phys ic
ian bu t m isqu ote d in his note as 4.1. T he re
have be e n no u ns c
he d u le d visits fors e izu re ac
tivity.
TB Infection Clinic
T he re we re no patients e nrolle d in the T B c
linicat the tim e ofou r visit. T his is ve ry s u rprising
give n the s ize ofthis ins titu tion and the fac
t that it is are c
e ption c
e nte r. Staffre viewe d allre c
e ption
c
harts and fou nd no ne w pos itive te s ts and only afe w s e lf-re porte d pos itive s . A lthou ghthis m ay
we llbe the c
as e , it raise d qu e s tions in ou rm ind s abou t the ac
c
u rac
y ofre ad ingthe P P D s kin te s ts .
Womens Health
P atients with ac
tive wom e n
s he alth iss u e s or who are at high risk for s u c
h are not trac
ke d or
m onitore d in an organize d way. T hu s , it was not s u rprisingthat we fou nd proble m s in e ight re c
ord s
(62% ) of 13 c
harts we re viewe d . T he m ajority of the iss u e s pe rtaine d to failu re to follow u p
abnorm alpaps m e ars orto pe rform tim e ly s c
re e ningin high-risk patients . W e note d that patients
typic
ally ge t aP aps m e ar on intake , bu t the re we re fre qu e ntly d e lays withs u bs e qu e nt follow-u p
c
are and rou tine P aps the re afte r, e s pe c
ially for H IV infe c
te d wom e n who re qu ire m ore fre qu e nt
sc
re e ningthan u ninfe c
te d wom e n.
T he re we re two ad d itionalc
as e s d e s c
ribe d in the s e c
tion title d R e s pons e s to the A ttorne y Le tte r;
one ofan ine xplic
able d e lay in the work-u pofapalpable bre as t m as s , and the othe rwho has not
be e n ad e qu ate ly e valu ate d forinc
ontine nc
e.
T he re is an obs te tric
ian-gyne c
ologist who provide s 24hou rs pe rwe e k ofons ite , whic
hd oe s not
appe ar to be s u ffic
ient forthis popu lation. T he fac
ility had re c
e ntly re c
ru ite d awom e n
s he alth
nu rs e prac
titione r, whic
hs hou ld im prove ac
c
e s s forthis popu lation.
Patient #1
T his is an H IV patient withhistory ofan abnorm alP ap s m e ar and aprior LEE P proc
e d u re. She
had an abnorm alP apin Janu ary 2012. A re pe at tes t in M arc
h2012was norm al. H e rm os t re c
e nt
te st was on 11/28/12and was ne gative . She has had no fu rthe rP aps m e ars .
Opinion:D u e to the ir inc
re as e d risk of invas ive c
e rvic
al c
anc
e r, c
u rre ntly pu blishe d e vid e nc
e
bas e d gu ide line s re c
om m e nd annu als c
re e ningforH IV infe c
te d wom e n.
Patient #2
T his is a45-ye ar-old withH IV infe c
tion who had an abnorm alP ap s m e ar in A u gu s t 2012. She
u nd e rwe nt c
olpos c
opy withbiops y in O c
tobe r2012, whic
hs howe d ac
u te and c
hronicc
e rvic
itis,
s qu am ou s m e taplas ia and tu bu lar m e taplas ia. She u nd e rwe nt c
ryothe rapy x 2 tre atm e nts on
12/6/12, withare c
om m e nd ation to re pe at the P aps m e arin s ix m onths . She was the n trans fe rre d
to Logan in M arc
h2013and no fu rthe re xam s have be e n d one .
A pril2014
L ogan C orrec ti
onalC enter
P age 19
Opinion:T his high-risk patient ne e d s afollow-u pP aps m e ar.

Patient #3
T his is a25-ye ar-old wom an withH IV infe c
tion who had an abnorm alP aps m e aron 3/6/13whic
h
te ste d H P V +. She u nd e rwe nt c
olpos c
opy withbiops y on 5/31/13;this re port was not in he rc
hart.
T he re has be e n no s u bs e qu e nt follow u pofthis iss u e .
Opinion:T his high-risk patient ne e d s afollow-u pP aps m e ar.
Patient #4
T his is a29-ye ar-old wom an withH IV whos e las t P aps m e arand pe lvice xam was on 4/11/12.
Patient #5
T his is a44-ye ar-old withH IV whos e las t P aps m e arwas on 11/27/12.
Patient #6
T his is a39-ye ar-old wom an who arrive d at Logan in M arc
h2013. H e r las t P ap s m e ar was on
1/3/11.
B os we llP harm ac
e u tic
als , loc
ou nte r
m e d ic
ations for the fac
h m e ans patients ne w
pre s c
riptions are faxe d to the pharm ac
y by 2:30 p.m . and willarrive at the fac
ility the ne xt d ay.
R e fillpre s c
riptions are faxe d by 10:00a.m . and willbe re c
e ive d the ne xt d ay. T he loc
alW algre e ns
s tore is the bac
k-u p pharm ac
y for obtainingm e d ic
ation whic
his ne e d e d im m e d iate ly and is not
available in s toc
k. P atient s pe c
ificpre s c
riptions , s toc
k pre s c
riptions and c
ontrolle d m e d ic
ations
arrive pac
kage d in a30-d ay bu bble pac
k. O ve r-the -c
ou nte rm e d ic
ations are provide d in bu lk by
the bottle , tu be , etc
. T he m e d ic
ation pre paration/storage are a is s taffe d with thre e fu ll-tim e
pharm ac
y te c
hnic
ians , and B os we llprovid e s ac
ons u ltingpharm ac
ist to c
om e on s ite onc
e am onth
to re view pre s c
ription ac
y te c
hnic
ian pe rform anc
e and te c
hniqu e and to
d e s troy ou td ate d orno longe rne e d e d c
ontrolle d m e d ic
ations pu rs u ant to the re qu ire m e nts ofthe
Fe d e ralD ru gA d m inistration (FD A ) and D ru gEnforc
e m e nt A ge nc
tion of the
m e d ic
ation pre paration/storage are a re ve ale d a large , c
le an, we ll-lighte d and ge ne rally we llm aintaine d are a. A n inte rview withthe le ad te c
hnic
ian re ve ale d aknowle d ge able ind ivid u alwith
23 ye ars workingas apharm ac
y te c
hnic
ian. Ins pe c
ate d tight ac
c
ou ntingof
c
ontrolle d m e d ic
ations , both s toc
k and re tu rn ite m s , ne e d le s /syringe s , s harps /ins tru m e nts and
m e d ic
ou nts ind ic
ate d allwe re ac
c
u rate .
A ll pre s c
riptions , c
ontrolle d m e d ic
ations , s yringe s , ne e d le s and othe r s harp tools are ord ere d ,
re c
y te c
hnic
ians . O nc
e re c
e ive d and c
ou nts ve rified , e ac
hof
the ite m s is ad d e d into the ite m s pe c
e d in bac
k s toc
k are
ke d and re s tric
te d ac
c
inve ntories for allite m s loc
ate d in the vau lt are ve rified two tim e s ad ay. M e d ic
ation c
arts are
inve ntoried d aily and re s toc
ke d as ne e d e d . T he c
ras hc
art inve ntory is ve rified m onthly orany
A pril2014
L ogan C orrec ti
onalC enter
P age 20
tim e the plas tics e c

u rity s e alis broke n. T he c
ontrolle d m e d ic
ation bac
k s toc
kpe rpetu alinve ntory
is ve rified two tim e s a d ay. T he pe rpe tu al inve ntories for c
ontrolle d m e d ic
ation in front or
workings toc
kis ve rified e ac
hs hift by an on-c
A c
c
pharm ac
y te c
hnic
ians . P harm ac
y te c
hnic
ians are re qu ire d to d raw ke ys to the ir are a at the
be ginningofe ac
hs hift and re tu rn the ke ys whe n le avingat the e nd ofthe irs hift. In the e ve nt the y
wou ld le ave ins titu tional grou nd s with the ke ys , the y are c
ontac
te d by arm ory pe rs onne l to
im m e d iate ly re tu rn to the ins titu tion. N u rs ings taffm e m be rs hand offthe ir ke ys be twe e n s hifts .
K e ys to the m e d ic
ation s torage room are re s tric
pharm ac
y te c
hnic
ians . K e ys to the bac
k s toc
te d to the H e alth C are U nit
A d m inistrator, D ire c
tor of N u rs ingand the thre e pharm ac
y te c
hnic
ians . In the abs e nc
e of the
pharm ac
y te c
hnic
ians , e m e rge nc
y proc
e d u re s are in plac
e fornu rs ings taff, u nd e rs u pe rvision, to
e nte r the vau lt and obtain ne e d e d ite m s . If this oc
c
u rs , a c
om ple te inve ntory of the vau lt is
c
ond u c
te d to ve rify pe rpe tu alinve ntories . A s e parate loc
ke d c
abine t is u s e d for the s torage of
inje c
table m e d ic
ations . A llm e d ic
ations in this c
abine t are m aintaine d on ape rpetu alinve ntory and
inve ntoried d aily. R e frige ratorte m pe ratu re s are m onitore d and d oc
u m e nte d d aily.
M e d ic
ation ad m inistration c
ons ists oftwo m e thod s . W ithm e thod 1, m e d ic
ation is ad m iniste re d
at c
e ll-s id e in the X -hou s e , whic
hhou s e s re c
e ption, s e gre gation and m axim u m -s e c
u rity inm ate s .
W ithm e thod 2, inm ate s m ove in large line s to the he althc
are u nit to re c
e ive the ir m e d ic
ation.
T he facility c
ontinu e s to u s e apape rm e d ic
ord (M A R ), and e ac
hd os e of
m e d ic
ation ad m iniste re d orre fu s e d is note d on the patient s pe c
ificM A R . T he ins titu tion is in the
proc
e s s oftrans itioningto an e le c
tronicm e d ic
alre c
ord (E M R ). O bs e rvation ofm e thod 1re ve ale d
m e d ic
ation ad m inistration by aLic
e ns e d P rac
tic
al N u rs e (LP N ), who prope rly id e ntified the
patients , ad m iniste re d the m e d ic
ation throu ghafood s lot port in the s olid c
e lld oor, obs e rve d the
inge s tion, pe rform e d am ou thc
he c
k and d oc
u m e nte d the ad m inistration on the M A R . A s e c
u rity
offic
e re s c
orte d the LP N d u ringad m inistration bu t pe rform e d no othe rfu nc
tion. O bs e rvation of
m e thod 2re ve ale d longline s ofpatients re portingto the he althc
are u nit and , the n, bas e d on the
firs t le tte r ofthe ir las t nam e , re portingto one of thre e wind ows for the ir m e d ic
ations . A s with
m e thod 1, the patient was prope rly id e ntified , the m e d ic
ation was ad m iniste re d , am ou thc
he c
k
was c
ond u c
te d and d oc
u m e ntation was provid e d on the patient s pe c
ificM A R .
Laboratory
Laboratory s e rvic
c
e s m e d ic
alc
ontrac
torprovid e s two FT E phle botom y pos itions to d raw and
pre pare the s am ple s fortrans port to U IC . R e s u lts are e le c
tronic
k to the fac
ility,
ge ne rally within 24 hou rs vias e c
u re fax line loc
ald e partm e nt. U IC re ports to
boththe fac
ility and Illinois D e partm e nt ofP u blicH e alth(ID P H )re portable c
as e s . T he re we re no
e.
A pril2014
L ogan C orrec ti
onalC enter
P age 21
Offsite Services/Emergencies
T he re is no logthat trac
ks e ithe ru rge nt c
alls from the hou s ingu nits oralogthat trac
ks patients
s e nt ou t on an e m e rge nc
y bas is. W e we re only able to ide ntify afe w re c
ord s bas e d on nam e s liste d
in the qu ality im prove m e nt m inu te s . T his is c
le arly not ac
c
e ptable . T he state s ys te m is not
provid ingad e qu ate ove rs ight ofthis s e rvic
e.
O fthe s ix re c
ord s we re viewe d , fou rwe re proble m atic
.
Patient #1
T his is a32-ye ar-old with d iabe te s , hype rte ns ion and c
oronary arte ry d ise as e . T his patient was
s e e n on 2/8/14at 3:00p.m . by the C hiefM e d ic
alO ffic
e rre s pond ingto ac
om plaint ofc
he s t pain.
T he patient was s e nt to the loc
alhos pitalviaparam e d ic
s . T he re are no offs ite s e rvic
e d oc
u m e nts
su c
has an E R re port. T he re is als o no re tu rn note whe n the patient c
he c
ke d bac
k into the fac
ility.
T he patient was s e e n on 2/9, one d ay afte rs he was s e nt ou t. T he re fore , it was in alllike lihood an
E R visit. T he abs e nc
e ofre c
ord s m ake follow-u pd iffic
u lt.
Patient #2
T his is apatient who was s e nt ou t forapos s ible ove rd os e . H owe ve r, the re is no note d oc
u m e nting
the s e nd ou t and no offs ite s e rvic
e re c
ord s and no retu rn note . T he e ntire e pisod e is u nd oc
u m e nte d .
T he ne xt patient is partic
u larly proble m atic
.
Patient #3
T his is a35-ye ar-old with as e izu re d isord e r. O n 12/30/13, at abou t 11:00 p.m ., the c
e llhou s e
c
ontac
te d the m e d ic
alu nit to re s pond to this patient, who was havings e izu re s . W he n the nu rs e
arrive d , the s e izu re s had c
e as e d and s he d oc
u m e nte d that s he obs e rve d no s e izu re s bu t le ft the
patient in the hou s ingu nit. T he re was no ad e qu ate as s e s s m e nt. O ne d ay late r, at 11:40p.m ., the
patient was fou nd in the hou s ingu nit havingas e izu re with blood arou nd he r m ou thand blood
d rippingfrom alac
e ration in the bac
k ofhe rhe ad . She was brou ght to the he althc
are u nit and s e nt
to the loc
alhos pital. T he re is no m e ntion ofc
ontac
tingthe phys ic
ian. T he patient was retu rne d at
4:00 a.m . on 1/1/14. T he re are no re c
ord s from the loc
alhos pital. T he phys ic
ian c
am e in on 1/1
and s aw the patient and ord e re d blood le ve ls ofhe ranti-s e izu re m e d s . T he re has be e n no followu ps inc
e by the phys ic
ian. T his patient s hou ld have be e n brou ght to the infirm ary afte rthe s e izu re
on the firs t night form ore c
are fu lobs e rvation and to be s e e n by ac
linic
ian. T his was as ignific
ant
nu rs ingbre akd own.
Patient #4
T his is a28-ye ar-old withs e izu re d isord e rwho was s e nt ou t by the phys ic
ian to ru le ou t u reteral
c
olic
. T he patient was s e e n afters he retu rne d on 1/27/14and was plac
e d on antibiotic
s alongwith
a ste nt in he r u rete r. She was followe d u p c
los e ly by the phys ic
ian u ntil 2/1, whe n s he was
d isc
harge d to the hou s ingu nit. T his is anothe rc
as e in whic
hthe hos pitalre c
ord s are lac
king.
Onsite Emergencies
A pril2014
L ogan C orrec ti
onalC enter
P age 22
Give n the abs e nc

e ofalog, we we re only able to id e ntify c
as e s throu ghinc
id e nt re ports . In the
fou rre c
ord s we re viewe d , thre e offou rwe re proble m atic
.
Patient #1
T his is a22-ye ar-old who fe llou t ofbe d twic
e on 12/5/13. A nu rs e s aw he rand d e c
id e d that the
patient s hou ld be ad d e d to the C M O list. T he nu rs e d id an inad e qu ate as s e s s m e nt, inc
lu d ingno
vitals igns . T he phys ic
ian s aw the patient and ord ere d afollow-u pvisit, whic
hne ve roc
c
u rre d .
Patient #2
O n 2/12/14, an offic
e rc
alle d from the hou s ingu nit and ind ic
ate d that this inm ate
sc
e llm ate s tate s
that s he was havingtrou ble bre athingand not re s pond ing. W he n anu rs e arrive d , the patient was
s ittingin the c
orne rc
ryingand not re s pond ing. T his nu rs e pe rform e d no as s e s s m e nt and the re was
no follow-u pofthis c
as e .
Patient #3
T his is apatient who in Fe bru ary ofthis ye arc
om plaine d ofc
he s t pain bu t was ne ve rs e e n witha
d oc
u m e nte d note and the patient was retu rne d to the hou s ingu nit.
Nursing Telephone Urgent Care Log

N one e xiste d at the tim e ofou rre view.

W e m e t withthe s c
he d u le rwho m aintains as ys te m oftrac
kingre qu e s ts , bu t only be ginningwith
the c
olle gialre view approval. T he re fore , s he is u naware ofthe d ate that the re qu e s t was s u bm itte d
by the c
linic
ian. T he s c
he d u le rind ic
ate d that s he ge ne rally re c
e ive s the au thorization le tte rwithin
one we e k ofthe ve rbalapprovald u ringthe c
olle gialre view and s inc
e s he obtains the appointm e nts
loc
ally, s he is u s u ally able to s c
he d u le the appointm e nts within two we e ks . O c
c
as ionally it m ay
take u pto two m onths . O ne ofthe proble m s at this fac
ility is that whe n patients re tu rn from the ir
offs ite s e rvic
e the y are not brou ght to the m e d ic
alare a. T his polic
y ne e d s to be im ple m e nte d in
ord erto ins u re that the pape rwork is re c
e ive d by the s c
he d u le ras s oon as pos s ible . Ifthe patient
re tu rns withou t the pape rwork, it is the re s pons ibility ofthe s c
he d u le rto c
ontac
t the offs ite s e rvic
e
in ord e rto retrieve the re ports .
W e re viewe d five s c
he d u le d offs ite proc
e d u re s . O fthe five re c
ord s re viewe d , the re we re two with
s ignific
ant proble m s .
Patient #1
T his is a25-ye ar-old withs e izu re s who we nt ou t to re c
e ive aC T s c
an ofthe he ad on 2/15/14. She
re tu rne d to the infirm ary bu t the re we re no note s and s he was the re fore not s e e n. N e ithe rwas s he
s e e n on 2/15and 2/16, d e s pite havingbe e n s e nt ou t.
Patient #2
T his is a29-ye ar-old withd iabe te s type 1and d iabe ticre tinopathy. She was s e nt ou t on 2/17/14
for retinals u rge ry and re tu rne d on 2/18. W e c
ou ld not find as u rgic
alre port and the note s we re
d ropfile d and the re fore not in c
hronologicord e r.
A pril2014
L ogan C orrec ti
onalC enter
P age 23
W e als o re viewe d five re c

ord s ofpatients s e nt ou t for c
ons u ltation. A m ajority ofthe s e re c
ord s
we re proble m atic
.
Patient #3
T his is a34-ye ar-old who was s e nt to E N T on 1/24/14. T he re was no c
ons u lt re port in the c
hart
norwas the re any note and no follow-u pvisit.
Patient #4
T his is a26-ye ar-old who has ps orias is and ahistory ofs e izu re s . She was s e nt ou t on 1/24/14to
E N T be c
au s e s he had ape rs iste nt e arinfe c
tion. She was s e e n bu t the re has be e n no follow-u pwith
the phys ic
ian and no ord e rc
ons iste nt withthe re c
om m e nd ation ofthe E N T s pe c
ialist.
Patient #5
T his is a29-ye ar-old withobe s ity who was s e nt ou t on 3/21/14to ahand s u rge on for aboxe r
s
frac
tu re withare fe rralfrom 3/9/14. T he re is no report from the 3/21visit and no follow-u p.
Infirmary Care
ate d at one e nd ofthe he althc
are u nit. T he re are atotalof20 be d s with15
m e d ic
albe d s , thre e m e ntalhe althc
risis room s and two ne gative air re s piratory isolation room s .
T he re is a c
e ntrally loc
ate d nu rs ings tation with d ire c
t line of s ight into fou r of the room s .
Ge ne rally, the u nit is s taffe d withone re giste re d nu rs e , bu t, on oc
c
as ion lic
e ns e d prac
tic
alnu rs e s
work the u nit. W he n this oc
c
u rs , the re is are giste re d nu rs e in the he althc
are u nit bu t not as s igne d
to the infirm ary.
O fthe 20be d s , 10 are trad itionals tyle hos pitalbe d s whe re the he ad ofthe be d c
an be e le vate d .
T he s e be d s have athic
k plas ticc
ove re d m attre s s . Five be d s have as te e lfram e withas olid bottom
and are approxim ate ly 18-24 inc
he s off the floor. T he s e be d s have athinne r plas ticc
ove re d
m attre s s . T he othe r five be d s are c
onc
re te , whic
h inc
lu d e s the two be d s in the ne gative air
re s piratory isolation room s . T he s e be d s are s olid c
onc
re te approxim ate ly 24to 30inc
he s highand
approxim ate ly 24 inc
he s wide . Inm ate s c
an be plac
e d on the s e be d s withe ithe r am attre s s orno
m attre s s . N u rs ings taffre porte d s u fficient qu ality and qu antity ofbe d line ns . Line ns are lau nd e re d
in the he althc
are u nit rathe rthan throu ghthe ins titu tionallau nd ry (s e e Infe c
tion C ontrols e c
tion).
A d d itionally nu rs ings taffre porte d s u ffic
ient e qu ipm e nt.
alls ys te m . A s are s u lt, patients have to s hou t orbe at on the irroom d oorin ord e r
to gain s om e one
s atte ntion. In the e ve nt the patient we re to be inc
apac
itate d , no staffm e m be rm ay
know u ntile ithe rthe nu rs e ors e c
u rity s taffwho m ake rand om 30m inu te rou nd s we re to find the
patient. T he infirm ary is an ope n hallway offthe m ain lobby ofthe H C U , thu s e xpos e d to allthe
noise and c
om m otion from the e ntryway whic
hc
re ate s ale s s than the rape u tice nvironm e nt.
A t the nu rs ings tation, the re are visu aland au d ible alarm s ind ic
atingwhe n ne gative air pre s s u re
has be e n los t in the re s piratory isolation room s .
A pril2014
L ogan C orrec ti
onalC enter
P age 24
O nly the M e d ic
alD ire c
tor is ad m ittingand d isc
hargingfrom the infirm ary. W e re viewe d five
re c
ord s of patients ad m itte d to or hou s e d in the infirm ary and fou nd no s ignific
ant iss u e s with
tim e line s s orqu ality ofthe c
are provide d in this s e tting. T he M e d ic
alD ire c
torrou nd s on the ac
u te
patients at le as t d aily, s om e tim e s m ore , and s om e tim e s on we e ke nd s . H e als o s e e s the c
hronic
patients ne arly d aily. H is d oc
u m e ntation is typic
ally thorou gh.
It s hou ld be m e ntione d that ou rre view was s ignific
antly ham pe re d by the poor c
ond ition ofthe
m e d ic
al re c
ord s . D rop filingis u s e d in the infirm ary, e ve n for the c
hronicad m iss ions , thu s
re nd e ringthe c
harts in ne arly c
om ple te d isarray.
P roble m s ide ntified in the infirm ary we re as follows :
1. V e ry d iffic
u lt to find inform ation d u e to two c
harts fore ac
hpatient be ingu s e d , withs om e
inform ation in one re c
ord and s om e inform ation in the othe r re c
ord with no obviou s
rationale as to what inform ation was in e ac
hfile .
2. T he m ajority ofthe s he e ts ofpape r in one file we re loos e rathe rthan be ingpe rm ane ntly
file d and allthe s he e ts ofpape rin the s e c
ond file we re loos e .
3. T he gre ate rm ajority ofthe d oc
u m e ntation is ou t ofc
hronologic
alord e r.
4. M e d ic
al s taff is c
harting on any page with ope n s pac
e rathe r than ke e ping the
d oc
u m e ntation in s e qu e ntialorc
hronologic
ald ate ord er.
5. C ou ld ne ve rfind phys ic
ian ad m iss ion ord e rs to the infirm ary, whic
hare re qu ire d by ID O C
polic
y.
6. R e giste re d nu rs e infirm ary ad m iss ion note s we re inc
ons iste ntly c
om ple te d . T his is an
ID O C polic
y re qu ire m e nt.
7. V itals igns d oc
u m e ntation was not c
ons iste ntly pe rform e d .
8. C ons u ltation re ports from s pe c
ialists c
ou ld not be fou nd .
9. SO A P note c
harting, whic
his ID O C policy, is ge ne rally not be ingu s e d . T he m ajority of
note s are in anarrative s tyle .
W e qu e s tione d one as pe c
t ofc
are in the c
as e d e s c
ribe d be low.
Patient #1
T his is a 50-ye ar-old fe m ale ad m itte d to the infirm ary on 3/27/14 for ac
u te panc
re atitis. She
pre s e nte d to the H C U afte rm id night on 3/27and the on-c
alld oc
torac
tu ally c
am e in and e valu ate d
the patient at 1:30a.m . on 3/27, inc
lu d ingape lvice xam . H e d e c
id e d to s e nd he rto the loc
alE D
whe re aC T s c
an s howe d panc
re atitis withs e c
ond ary c
olitis and d u od e nitis. H e rwhite c
ou nt was
e le vate d bu t panc
re atice nz ym e s we re norm al. H owe ve r, by the ne xt d ay he rlipas e was ove r1000.
She was s e nt bac
k to the prison afte rd isc
u s s ion be twe e n the E R phys ic
ian and fac
ility phys ician.
T he phys ic
ian d id he rad m iss ion H & P late ron the m orningof3/27(8:00a.m .), whic
hwas qu ite
thorou gh. She was tre ate d with IV flu id s bu t IM pain m e d ic
ation. T he M e d ic
al D ire c
tor
d oc
u m e nte d that he d isc
u s s e d the c
as e withthe W e xford M e d ic
alD ire c
tor, who ad vise s IM bu t
no IV opiate in the prison s e tting.T he patient was s e e n d aily by the M e d ic
alD ire c
tor, inc
lu d ing
on Satu rd ay, 3/29.
Opinion:U s ingthe e s tablishe d IV ac
c
e s s forthe d elive ry ofpain m e d ic
ation wou ld like ly be m ore
e ffe c
tive and le s s u nc
om fortable forthis patient.
A pril2014
L ogan C orrec ti
onalC enter
P age 25
Infection Control
A t pre s e nt, the re is no nam e d infe c
tion c
ontrol nu rs e . T he H e alth C are U nit A d m inistrator is
re s pons ible for c
om plianc
e with ID O C polic
yc
onc
e rningc
om m u nic
able d ise as e s , blood borne
pathoge ns and c
om plianc
e withIllinois D e partm e nt ofP u blicH e althre portingre qu ire m e nts .
A lls taffare traine d initially and annu ally on the ID O C blood -borne pathoge n polic
y.
T he fac
ility has ac
ontrac
t withanationalc
om m e rc
ialm e d ic
om pany, whic
h
c
om e s on-s ite two tim e s pe rm onthand as re qu e s te d to hau laway m e d ic
alwas te . T he re we re no
re porte d iss u e s withthis s e rvic
e.
Ins pe c
tion ofthe infirm ary, s ic
kc
ald e partm e nt and X -hou s e and e m e rge ncy
re s pons e bags ve rified the pre s e nc
e ofpe rs onalprote c
tu re proofc
ontaine rs
forthe d ispos alofs harps are in u s e in allm e d ic
alare as and are appropriate ly plac
e d in the m e d ic
al
was te c
R e portable ST Is are ide ntified by U IC and re porte d to the ins titu tion. T he c
hronicillne s s c
linic
nu rs e s and re c
e ption and c
las s ific
ation nu rs e are re s pons ible to m e e t the re portingre qu ire m e nts to
the Illinois D e partm e nt ofP u blicH e alth.
Inm ate porte rs , u nd e r the s u pe rvision of both s e c
d u ties ;porte rs d o not pe rform or have involve m e nt in any m e d ic
al c
are d e live ry. P orters are
provide d an orientation to the he alth c
are u nit, whic
h inc
lu d e s prope r c
le aningand s anitation
proc
e d u re s , blood -borne pathoge n trainingand c
om m u nic
ate d ,
the y are provide d pe rs onalprote c
tive e qu ipm e nt. B od ily flu id c
le an u p wou ld be s u pe rvise d by
nu rs ings taff.
P orte rs are re s pons ible for lau nd e ringinfirm ary line ns . T his is of c
onc
e rn, in that allinfirm ary
line ns m u s t be c
ontam inate d and , as are s u lt, m u s t be lau nd e re d appropriate ly.
T he re qu ire d lau nd e ringproc
e d u re to s anitize line ns is to was hwithlau nd ry d e te rge nt at awate r
te m pe ratu re ofat le as t 160d e gre e s Fahre nhe it foram inim u m of25m inu te s orwas hwithlau nd ry
d e te rge nt and able ac
h bath of at le as t 100 ppm at awate r te m pe ratu re of at le as t 140 d e gre e s
Fahre nhe it for am inim u m of10 m inu te s . It is d ou btfu lthe he althc
are u nit lau nd ry room wate r
te m pe ratu re is ove r120-130d e gre e s and , as are s u lt, s hou ld not be u s e d to lau nd e rinfirm ary line ns .
T he wate rte m pe ratu re s hou ld be raise d to am inim u m 140d e gre e s and ble ac
hprovide d or, ifthe
u s e of ble ac
h is not pe rm itte d , the wate r te m pe ratu re m u s t be raise d to 160 d e gre e s or the
ins titu tional lau nd ry m u s t be u s e d . W ate r te m pe ratu re s in the ins titu tional lau nd ry m u s t be
m onitore d and m aintaine d at the re qu ire d te m pe ratu re s .
Responses to the Attorney Letter

W e re viewe d the re c
ord s of15patients whos e c
om plaints are d e s c
ribe d in ale tte rd ate d Fe bru ary
9, 2014from attorne y M argare t B yrne . In ne arly allofthe s e ins tanc
e s , the alle gation in the le tte r
was s u bs tantiate d by the re c
ord re view. T he s e c
as e s d e m ons trate d an abs e nc
e ofc
ons c
ientiou s ne s s
on the part ofhe althc
are s taff.
A pril2014
L ogan C orrec ti
onalC enter
P age 26
Patient #1
T his is a36-ye ar-old fe m ale who has had apalpable bre as t m as s withnipple d isc
harge forove ra
ye ar. She has afam ily history ofbre ast c
anc
e rin he rm othe r(age 56). C hart re view re ve ale d that it
took ove raye arto obtain abiops y. A m iss e d d iagnos is ofbre as t c
anc
e ris one ofthe m ost c
om m on
c
au s e s of m alprac
tic
e c
laim s in the U nite d State s. A c
c
ord ingto the c
u rre nt m e d ic
al lite ratu re,
palpable m as s e s s hou ld be biops ied . It s hou ld not have take n ove raye arto obtain this re lative ly
low risk proc
e d u re whic
his ac
ru c
ialpart ofthe work-u p. W hile the pathology ofthis m as s was not
ye t m alignant, it strongly s u gge s te d ahighrisk ofprogre s s ion to c
anc
e r.
Patient #2
T his is a55-ye ar-old wom an who was re porte d ly told in Se pte m be r2013that s he wou ld be s e e n
by the gyne c
ologist for he r inc
ontine nc
e . C hart re view c
onfirm e d that s he was re fe rre d to the
gyne c
ologist on 9/28/13bu t had not be e n s e e n as ofthe d ate ofou rre view. She als o has bac
k and
s hou ld e r pain for whic
hs he has not be e n s e e n by aprovide r. W e d isc
u s s e d this c
as e withs taff,
who wills c
he d u le he rwithaprovide r.
Patient #3
T his is a62-ye ar-old wom an who arrive d at Logan in M arc
h2013withahistory ofhype rte ns ion,
hypothyroid ism d u e to prior thyroid c
anc
e r, and a pitu itary tu m or tre ate d with s u rge ry and
rad iation. C hart re view s hows that the M e d ic
alD ire c
torre fe rre d the patient for s pe c
ialty follow
u p in Ju ly 2013. A s ofthe d ate ofou r visit m ore than e ight m onths late r, s he had s tillnot be e n
s e e n.
Patient #4
T his is a50-ye ar-old with s e ve re d e ge ne rative arthros is of he r kne e and c
laim s to ne e d akne e
re plac
e m e nt. C hart re view c
onfirm s that totalkne e arthroplas ty had be e n re c
om m e nd e d by an
orthope d ics u rge on prior to he r arrivalat Logan;howe ve r, the re qu e s t was d e nied by c
olle gial
re view afte rhe rarrivalat this ins titu tion. U pon re viewinghe rc
hart, it is abu nd antly c
le arthat this
patient d oe s in fac
t re qu ire akne e re plac
e m e nt. P hys ic
althe rapy willnot he lphe r. T his c
as e was
d isc
u s s e d withs taff, who re port that the y willpre s e nt the c
as e to c
olle gialre view again and are
pre pare d to appe alifit is d e nied .
Patient #5
T his is a43-ye ar-old wom an witharthritis who c
om plains that he ranti-inflam m atory m e d ic
ation
has not be e n re ne we d . R e c
ord re view c
onfirm s that it has not be e n ord e re d s inc
e he rlas t provide r
visit on 7/21/13, at whic
htim e s he got athre e -m onths u pply.
Patient #6
T his is a53-ye ar-old wom an who arrive d at Logan in M ay 2013. She has c
hronicbac
k pain d u e to
s e ve re d e ge ne rative arthritis whic
hs he as s e rts is be ingtre ate d inad e qu ate ly. Sinc
e he rarrival, s he
has be e n s e e n onc
e by aphys ic
ian for he r bac
k pain. T he phys ic
ian ord e re d m e d ic
ations and
re qu e s te d follow u p at M D line in two m onths , bu t this d id not oc
c
u r. H e r pain m e d ic
ation was
late r d isc
ontinu e d withou t avisit withthe patient. It was not pos s ible to d ete rm ine the e xte nt of
this patient
s bac
k proble m by the d oc
u m e ntation in the he alth re c
ord , as s he has not be e n
ad e qu ate ly e xam ine d .
Patient #7
A pril2014
L ogan C orrec ti
onalC enter
P age 28
27
T his is a48-ye ar-old wom an withs e ve re kne e arthritis who as s e rts that s he re qu ire s s u rge ry and
that s he c
annot walk d u e to pain. She was re fe rre d to orthope d ics u rge ry, bu t this re qu e s t was
d e nied by c
olle gialre view on 10/1/13on the bas is ofobe s ity. H e r we ight was 238 pou nd s . T he
d e gre e of obe s ity at whic
h kne e re plac
e m e nt is d e fe rre d is a d e c
ision typic
ally m ad e by the
s u rge on, not the re fe rringd oc
tor. T he alte rnate plan was phys ic
althe rapy;the re are no phys ic
al
the rapy note s in the c
hart. She has be e n m anage d withanti-inflam m atories and s te roid inje c
tions .
O n 3/24/14, the M e d ic
al D ire c
tor ind ic
ate d that he wou ld pre s e nt he r c
as e again to c
olle gial
re view. T he re we re no fu rthe rnote s in the c
hart as ofthe d ate ofou rvisit.
Patient #8
T his is an ins u lin re qu iringd iabe ticwith ankle pain who c
om plains that he r ins u lin has be e n
c
hange d withou t he rinpu t, and that he rankle pain is not be ingtre ate d , norhas he rs kin lotion be e n
re ne we d . C hart re view re ve als that this patient
s ins u lin was ind e e d c
hange d s e ve raltim e s withou t
ac
orre s pond ingvisit. H owe ve r, he r d iabe te s has c
om e u nd e r be tte r c
ontrold u ringhe r tim e at
Logan as re fle c
te d in he rm os t re c
e nt blood work. N one ofthe provide rnote s s pe c
ific
ally ad d re s s
ankle proble m s , bu t s he has be e n pre s c
ribe d pain m e d ic
ation on are gu lar bas is. T he re is no
m e ntion ofs kin lotion.
Patient #9
T his patient was u nable to get m e d ic
ations , whic
hwou ld not have happe ne d had s he be e n c
orre c
tly
e nrolle d in the c
hronicd ise as e c
linic
.
Patient #10
T his patient als o s hou ld have be e n e nrolle d in a c
hronicc
linicand the re fore d id not re c
e ive
m e d ic
ations on are gu lar bas is. A fe w we e ks be fore ou r visit, s he was s e e n by aphys ic
ian who
ord ere d anti-hype rte ns ive m e d ic
ation foraye ar, bu t s he has s tillnot be e n e nrolle d in the c
hronic
d ise as e program .
Patient #11
T his patient has arhe u m atologicd isord e rforwhic
hs he was s e e n in Fe bru ary 2013. She was to be
followe d u pin two m onths , bu t this has not oc
c
u rre d . H e rfollow-u pappointm e nt is m ore than a
ye arove rd u e . She ne e d s arhe u m atology appointm e nt.
Patient #12
T his patient is anothe rwhos e m e d ic
ations we re d isru pte d . She was told to pu t in as ic
kc
allre qu e s t
for m e d ic
ation re ne wal. H ad the patient be e n e nrolle d in the c
hronicd ise as e program and s e e n
re gu larly ac
c
ord ingto polic
y, this like ly wou ld not have happe ne d .
Patient #13
T his patient was s e e n in the hype rte ns ion c
linicbu t was c
harge d for the visit and the re c
ord
s u bs tantiate s this alle gation. T he re are s om e proble m s withnu rs inginte rpre tation ofs om e polic
ies .
W e we re told , and this was c
onfirm e d by the le ad e rs hipte am , that som e nu rs e s have told patients
that the y c
annot be re fe rre d on to an ad vanc
e d le ve lc
linic
ian u ntilthe y have be e n s e e n by anu rs e
thre e tim e s . T his is abs olu te ly u ntru e . In 1984, we im ple m e nte d apolic
y
re qu iringnu rs e s who have u s e d aprotoc

olto ad d re s s aproble m to be m and ate d to re fe ron to an
ad vanc
e d le ve lprovid e rifthe patient pe rc
e ive s alac
k ofre s pons e afte rtwo nu rs e s ic
kc
allvisits .
A pril2014
L ogan C orrec ti
onalC enter
P age 29
T his was d one to prote c

t the patient
s ac
c
e s s to ad vanc
e d le ve lc
linicians . N ow that polic
y has
be e n tu rne d on its he ad by this nu rs ings taff, who have tu rne d it into an obs tac
le to gettingto an
ad vanc
e d le ve lc
linic
ian. T his m u s t be c
hange d im m e d iate ly.
In ad d ition, we we re told and this was ve rified by othe r s taff, that the re was an ins tru c
tion that
bothnu rs e s and c
linic
ians s hou ld only ad d re s s one proble m at an e nc
ou nte r. T his ofc
ou rs e c
re ate s
the im pre s s ion am ongthe patients that this polic
y is introd u c
e d pu re ly to ge ne rate m ore re ve nu e
throu ghad d itionals ic
kc
alls lips . N e ithe rc
linic
ians nornu rs e s s hou ld be lim ite d by as e t nu m be r
ofproble m s that the y c
an ad d re s s . Ifapatient has ale ngthy list, it is c
om m on to te llthe patient to
c
hoos e the thre e m os t im portant proble m s and you willd e alwiththos e and the n the othe rs at a
s u bs e qu e nt visit. B u t te llingthe patient you as ac
linic
ian willonly d e alwithone proble m at an
e nc
ou nte ris u nac
c
e ptable .
Dental Program
Executive Summary
O n M arc
h31 and A pril1-2, 2014, ac
om pre he ns ive re view ofthe d e ntalprogram at Logan C C
was c
om ple te d . Five are as ofthe program we re ad d re s s e d to inc
lu d e :1)inm ate s ac
c
e s s to tim e ly
d e ntalc
y of
the fac
ility and e qu ipm e nt d e vote d to d e ntalc
are ;and 5)the ove ralld e ntalprogram m anage m e nt.
T he c
linicits e lfc
ons iste d oftwo c
hairs forc
e d into as m all, s ingle s pac
e . Fre e m ove m e nt arou nd
e ac
hu nit was lim ite d and d iffic
u lt. T he re was as e parate d e ntallaboratory and s te rilization are aof
ad e qu ate s ize . A s e parate offic
e room was available for s taff. T wo ad d itionalc
hairs are be ing
ad d e d at this tim e . O ne willbe available forthe hygienist.
T he e qu ipm e nt is ve ry old and worn. T he u nits are ove r20ye ars old , fad e d and c
orrod e d , and not
u pto c
onte m porary infe c
tion c
ontrols tand ard s . C hairs had torn fabric
. C abine try was ru s te d and
bad ly s taine d . T he intraoralrad iographu nit was ve ry, ve ry old and not in u s e . T he pane lips e u nit
was als o ve ry old .
A m ajorare aofc
onc
e rn re late s to c
om pre he ns ive c
are was provide d withou t
ac
om pre he ns ive intra and e xtra-oral e xam ination and a we ll d e ve lope d tre atm e nt plan. N o
e s s . B ite wing
or periapic
alrad iographs we re ne ve r take n to d iagnos e c
aries . R e s torations we re provide d from
the inform ation on apane lips e rad iograph. O ralhygiene ins tru c
tions we re not d oc
u m e nte d in the
d e ntalre c
ord .
A s im ilar are a of c
onc
e rn is d e ntal e xtrac
e e d from a
d oc
the re c
ord s re viewe d was ad iagnos is orre as on forthe e xtrac
tion d oc
u m e nte d .

ons tru c
e ofc
are d e live ry inc
lu d e d in
the c
om pre he ns ive c
are proc
proc
tre atm e nt was s e ld om provide d . O ralhygiene ins tru c
lu d e d . It was alm os t
im pos s ible to d e m ons trate that allfillings and e xtrac
tions we re c
u m e nte d .
A t Logan C C , d e ntals ic
kc
allis ac
c
e s s e d throu ghthe inm ate re qu e s t form . T he d e ntals taffre views
the re qu e s t form whe n re c
e ive d and u rge nt c
are requ e s ts are s e e n the s am e orne xt workingd ay.
N on-u rge nt re qu e s ts are s c
he d u le d fore valu ation within 14d ays . T he re qu e s t form s we re thrown
away and not be ingfile d .
T he SO A P form at was not be ingu tilize d . T re atm e nt was provide d withlittle inform ation ord etail
pre c
e d ingit. R e c
ord e ntries d id not inc
lu d e c
linic
alobs e rvations orad iagnos is to ju s tify tre atm e nt.
R ou tine c
are was ofte n provid e d on s ic
kc
allappointm e nts .
A we ll d e ve lope d polic
y and proc
e d u re s m anu al ins u re s that a d e ntal program ad d re s s e s all
ontinu ity. T he polic
y and proc
e d u re s m anu alat Logan C C is old
and ou td ate d . It d oe s not ad d re s s the m anagingand ru nningofthe d e ntalprogram . It has not be e n
re viewe d orre d e ve lope d s inc
e Logan C C c
hange d its m iss ion to afe m ale ins titu tion and re c
e ption
c
e nte rs e ve ralm onths ago.
D e ntalc
are is not ad d re s s e d in the Logan C C O ffe nd e rH and book and O rientation M anu al.
linic
ians ind ic
A loos e m e talju nc
tion box was on the floorin the c
linicare athat re c
e ive d s e ve rale le c
tric
alc
ord s .
T he box was u pright and in the pathoftrafficflow. It pre s e nte d are als afe ty haz ard . T he re was no
biohaz ard labe lpos te d in the s te rilization are a. Safe ty glas s e s we re not always worn by patients .
A rad iation haz ard warnings ign was not pos te d in the x-ray are as . N o c
ons e nt form s we re available
forpre gnant inm ate s to c
ons e nt to x-rays .
T he c
ontinu ingqu ality im prove m e nt proc
e s s was none xiste nt. D e ntalonly c
ontribu te d m onthly
d e ntals tatistic
s . N o C Q I s tu d ies we re in plac
e . O ngoingC Q I s tu d ies s hou ld be d e ve lope d to
ad d re s s program d e fic
ienc
ies note d in the bod y ofthis re port.

Logan C C has ad e ntals taffoftwo fu ll-tim e d e ntists , two fu ll-tim e as s istants , and one fu ll-tim e
hygienist. T his s hou ld be ad e qu ate to provide m e aningfu l d e ntal s e rvic
e s for Logan
s 2000
inm ate s . A llthe s taffare c
ontrac
es.
C P R trainingis c
e s s ary lic
forthe d e ntists .
A pril2014
L ogan C orrec ti
onalC enter
P age 30

O ve rall, the e xistinge qu ipm e nt is ve ry old and bad ly worn. T he c
linicits e lfc
ons ists oftwo c
hairs
forc
e d into ave ry s m alls pac
e . I was told that the u nits we re ove r20ye ars old . T he c
hairs are ve ry
old withtorn and fad e d fabric
. T he u nits are old and fad e d and not u pto c
onte m porary infe c
tion
c
ontrols tand ard s . Se ve ralare as ofru s te d m e talwe re e vide nt. T he c
abine try was ve ry old , worn
and fad e d . M e tallics u rfac
e s we re ru s ty and s taine d and c
orne rs we re worn and fraye d . Good
s u rfac
e d ec
ontam ination and d isinfe c
tion was alm os t im pos s ible . T he rad iograph u nit was an
antiqu e . It was s o old that it was no longe r in u s e . T he ability to take bite wingand pe riapic
al
rad iographs is e s s e ntialto the provision ofd e ntalc
are . It took u palot offloors pac
e and inte rfe re d
withe ffic
ient c
linicflow and c
are d e live ry. T he pane lips e rad iographicu nit was old and fad e d .
T he rad iographs we re ofarathe rpoorqu ality. In the c
linicits e lf, loos e wire s we re s tre wn on the
floorand plu gge d into aloos e m e talju nc
tion box, u pright on the floorne xt to the u nit. It inte rfe re d
with u nim pe d e d and e ffic
ient m ove m e nt in the c
linicand pre s e nte d are als afe ty haz ard . T he
ins tru m e ntation was ad e qu ate and ofgood qu ality. T he hand piec
e s we re ad e qu ate and fu nc
tioning.
T he c
linicits e lfc
ons iste d oftwo c
hairs forc
e d into arathe r s m all, s ingle s pac
e . Fre e m ove m e nt
arou nd e ac
hu nit was lim ite d and d iffic
u lt. P rovid e rand as s istant had ve ry little room to work, and
if both c
hairs are in u s e , the provide rs c
an inte rfe re with e ac
h othe r. T he re was a s e parate
s te rilization and laboratory room ofad e qu ate s ize . It had alarge work s u rfac
e and alarge s ink to
ac
c
om m od ate prope rinfe c
tion c
ontroland s te rilization. Laboratory e qu ipm e nt was in as e parate
c
orne r of the room . T he s taff had as e parate room for offic
e s pac
e . It had two d e s ks and was
ad e qu ate . A t the tim e of m y visit, two ad d itional u nits we re be ingins talle d in anothe r room
ad jac
e nt to the c
linicare a. T he s pac
e was rathe rs m allbu t s u ffic
ient to provide c
are . I was told the
room was to be u tilize d forhygiene c
are and pros the tic
s , and has an e xtrac
hairto ac
c
om m od ate
patient ove rflow, e .g., e m e rge nc
ies and e xam inations .
Recommendations:
1. T he s pac
e that is u s e d for the c
linicprope r and hou s e s the two m ain d e ntalu nits is too
s m allto allow e ffic
ient c
are flow and any s e ns e of privac
y. E nlarge m e nt of this s pac
e
s hou ld be c
ons id e re d fore ffic
ient c
are d e live ry and s afe ty c
ons id e rations .
2. A lle le c
tricou tle ts s hou ld be wallm ou nte d orprote c
te d by the c
ove rforthe ju nc
tion box
at the foot ofthe c
hair. Loos e wire s s hou ld be ne atly arrange d and ou t oftrafficflow as
m uc
has pos s ible .
3. A llofthe u nits , c
hairs and c
abine try s hou ld be re plac
e d witham ore c
onte m porary d e s ign
and of be tte r qu ality. Failu re of the e xistinge qu ipm e nt is im m ine nt and re pair of old e r
e qu ipm e nt is d iffic
u lt and c
ostly. Su rfac
e are as s hou ld be be tter able to ac
c
om m od ate
d isinfe c
tion.
4. T he rad iographu nit in the c
linicne e d s to be re plac
e d im m e d iate ly withawall-m ou nte d
u nit c
apable of d igitalrad iography. A n e le c
tronicm e d ic
alre c
ord is in the e arly te s ting
phas e at Logan C C . T he e xistingu nit is u ns afe and not be ingu s e d .
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5. T he pane li
ps e rad iographu nit s hou ld be re plac
e d . It is old and worn and the rad iographs of
rathe rpoorqu ality. A re c

e ption fac
ility s u c
has Logan C C ne e d s ac
om ple te ly fu nc
tioning
and re liable pane lips e m ac
hine .

hniqu e s and proc
e d isinfe c
tion was
tants we re be ing
u s e d . P rote c
tive c
es.
abine ts reve als that the y we re allprope rly bagge d and
s te rilize d . A llhand piec
le an m e t
ac
c
T he re was aloos e m e talju nc
tion box in the c
linicthat re c
e ive d s e ve rale le c
tric
alc
ord s from au nit.
T he box was u pright and in the path of trafficflow. T his c
re ate d an u ns afe e le c
tric
al haz ard ,
e s pe c
ially from awate rs pill.
Safe ty glas s e s we re not always worn by patients . E ye prote c
tion is always ne c
e s s ary, forpatient
and provide r.

Logan C C re c
e ntly c
hange d m iss ions , be c
om ingafe m ale ins titu tion. Staffinghas c
hange d to
ac
c
om m od ate this and the c
los ingofanothe r ins titu tion. I looke d bac
k two ye ars and fou nd the
s te rilization logs to be in plac
e . T he y s howe d that au toc
lavingwas ac
c
om plishe d we e kly and
d oc
u m e nte d . T he y u tilize as e rvic
e from H e nry Sc
he in c
alle d C ros te x that d oe s the te s tingand
m aintains the re s u lts . Ifare s u lt is ne gative , the y notify the ins titu tion. A s pre ad s he e t ofthe re s u lts
is available and provide d on aye arly bas is. N o ne gative re s u lts we re obtaine d . I d id obs e rve that
no biohaz ard warnings ign was pos te d in the s te rilization are a.
Recommendations:
1. T he loos e m e talju nc
tion box on the floor s hou ld be wallm ou nte d and in aloc
ation that
d oe s not inte rfe re withtrafficflow. E le c
tricc
ord s s hou ld be ne atly arrange d .
Comprehensive Care
W e re viewe d 10 d e ntalre c
ord s of inm ate s in ac
tive tre atm e nt c
las s ified as C ate gory 3 patients .
are proc
eed
plan, to inc
lu d e allne c
e s s ary d iagnos ticx-rays . In none ofthe 10re c
ord s re viewe d was any ofthis
pre s e nt. N o c
om pre he ns ive e xam ination was pe rform e d , no tre atm e nt plans d e ve lope d , and no
hygiene c
are pe rform e d be fore rou tine c
are . A d d itionally, no d iagnos ticx-
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rays forc
aries we re available . R e s torations we re provide d from the inform ation from the panore x
rad iograph and an inad e qu ate s c
re e ninge xam . T his rad iograph is not d iagnos ticfor c
aries . A
pe riod ontalas s e s s m e nt was ne ve r d one . Fu rthe r, oralhygiene ins tru c
tions we re not d oc
u m e nte d
in the d e ntalre c
ess.
Recommendations:
u m e nte d
tre atm e nt plan.
tiss u e s .
3. A ppropriate bite wingorperiapic
aries .
4. H ygiene c
ess.
5. T hat c
e s and d e ntal
prophylaxis.
6. T hat oral hygiene Ins tru c
tions be provid e d and d oc
u m e nte d as part of the tre atm e nt
proc
ess.
Dental Screening
Logan C C is the only R e c
e ption C e nte r forfe m ale offe nd e rs . I visite d the s c
re e ninge xam room
and obs e rve d the e xam ination proc
e s s . T he intraand e xtraorale xam inations we re s u ffic
iently
ad e qu ate . P anoram icx-rays we re take n at the d e ntalc
linic
. In allofthe d e ntalre c
ord s re viewe d ,
the s c
re e ninge xam ination was pe rform e d within 10d ays , panoram icx-rays we re take n and A P H A
priorities we re d e s ignate d .
In none ofthe re c
ord s we re oralhygiene ins tru c
tions inc
lu d e d . T he e xam ine re xplaine d ve rbally
and had writte n ins tru c
tions available on how to ac
c
e s s d e ntalc
are . O bs e rvation ofthe room whe re
the panoram icx-ray was take n s howe d that the aread id not provide s u ffic
ient warningto pre gnant
fe m ale s that the are awas pote ntially haz ard ou s . A d d itionally, no c
ons e nt form was d e ve lope d that
e xplaine d the pote ntialhaz ard s and gave pe rm iss ion forthe x-rays to be take n on fe m ale inm ate s
who m ay be pre gnant.
Recommendations:
1. O ral hygiene ins tru c
tions be provid e d to the inm ate s at the tim e of the s c
re e ning
e xam ination.
2. T he are awhe re x-rays are be ingtake n have warnings igns poste d that c
le arly warn of
pote ntialrad iation haz ard s to pre gnant fe m ale s .
3. C ons e nt form be d e ve lope d and u s e d forpre gnant fe m ale s that e xplains rad iation haz ard s
and give s the e xam ine rpe rm iss ion to take the x-ray.
Extractions
u m e nte d
d iagnos is. In none ofthe 10re c
ord s e xam ine d was ad iagnos is orre ason fore xtrac
tion inc
lu d e d as
part ofthe e ntry.
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Recommendations:
1.
A d iagnos is or are as on forthe e xtrac
tion be inc
ord e ntry.
T his
is
be s t ac
c
ially fors ic
kc
alle ntries .
hd e tailthat is s e riou s ly lac
kingin m os t d e ntale ntries obs e rve d . T oo
ofte n, the d e ntalre c
ord inc
lu d e s only the tre atm e nt provide d withno e vid e nc
e as to why
that tre atm e nt was provid e d .
s s hou ld proc
ord e d on
om ple te d . T he pe riod ontal, ope rative and orals u rge ry ne e d s allne e d to be
ad d re s s e d firs t. In none of the five re c
e ivingre m ovable partial
d e ntu re s we re oralhygiene ins tru c
tions provide d . P e riod ontalas s e s s m e nt is ne ve rinc
lu d e d , bu t in
thre e ofthe five re c
ord s aprophylaxis and /oras c
alingd e brid e m e nt was provide d . B e c
au s e the re
is no c
om pre he ns ive e xam ination orany tre atm e nt plans d oc
u m e nte d in any ofthe re c
ord s , it is
alm os t im pos s ible to as c
e rtain that ope rative or oral s u rge ry tre atm e nt is c
om ple te prior to
fabric
ation ofre m ovable partiald e ntu re s . I u s e d rad iographs and re c
ord e ntries to c
onc
lu d e that
e xtrac
tion we re probably c
om ple te d .
Recommendations:
1. A c
u m e nte d tre atm e nt plans ,
inc
lu d ingbite wingand /or pe riapic
alrad iographs , pre c
e d e allc
are ,
inc
lu d ingre m ovable pros thod ontic
s.
e s s and that the
e e d ingwithim pre s s ions . T hat oralhygiene ins tru c
tions
be provide d .
3. T hat all ope rative d e ntistry and oral s u rge ry be c
e e d ing with
im pre s s ions .
Dental Sick Call

Inm ate s ac
c
e s s s ic
kc
tc
allfrom as taffm e m be r,
ifit is pe rc
y. T he d e ntalhygienist re views allre qu e s t form s the following
d ay from the c
olle c
tion of the form s . She triage s the c
om plaints and s c
he d u le s pe r the d e ntists
d ire c
tion oras s oon as pos s ible . B y polic
y, allinm ate s who s u bm it are qu e s t form are to be s e e n
by d e ntals taffwithin 14d ays . Logan C C was in c
om ple te c
om plianc
e withthis polic
y. Im m e d iate
toothac
he s orinfe c
tions c
an be c
alle d in from anywhe re in the ins titu tion and the inm ate willbe
s e e n that s am e d ay.
ord s re viewe d was the SO A P form at be ingu s e d . A s are s u lt, tre atm e nt
was u s u ally provid e d withlittle inform ation or d etailpre c
e d ingit. T he u s e ofthe SO A P form at
wou ld ins u re that awe lld e ve lope d d iagnos is wou ld pre c
e d e alltre atm e nt. A ls o, rou tine c
are was
ofte n provide d at the s e appointm e nts , always withou t ac
om pre he ns ive e xam ination ortre atm e nt
plan. T he Logan C C d e ntal d e partm e nt d oe s not ke e p re qu e s t form s on file . It was the re fore
d iffic
u lt to re view s ic
kc
allre c
ord s from m ore than am onthago.
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onalC enter
P age 34
Recommendations:
kc
alle ntries . It willins u re that the inm ate
s
c
hief c
om plaint is re c
d iagnos is pre c
2. Save and ke e pallinm ate re qu e s t form s on file . In the d e ntalre c
ord wou ld be the e as ies t.
3. P rovid e only im m e d iate or palliative c
are on s ic
kc
allappointm e nts . D o not u s e the s e
appointm e nts forrou tine c
are . P rovide ad e d ic
ate d s c
he d u lingforthe s e inm ate s .
Treatment Provision
e that prioritize s tre atm e nt ne e d s . A llinm ate s who s u bm it are qu e s t form
are s e e n the followingd ay for e valu ation and the ir tre atm e nt ne e d s are prioritize d . U rge nt c
are
ne e d s are ad d re s s e d that d ay. O the rs are s c
he d u le d ac
c
ord ingly orplac
e d on the rou tine tre atm e nt
list.
Inm ate s c
ontac
tingLogan C C s taff, who willthe n c
allthe d e ntalc
s
c
om plaints from inm ate s
withu rge nt c
are ne e d s (c
om plaint ofpain ors we lling)are s e e n at le as t by the followingworking
d ay. M id -le ve lprac
om plaints . T he y
c
an provid e ove r the c
ou nte r pain m e d ic
ation or c
allm e d ic
al/d e ntals taff if the y fe e l m ore is
ne e d e d .
are are e valu ate d the ne xt workingd ay and plac
ed
are . T he waitinglist is approxim ate ly s ix m onths long.
Recommendations: N one . T he s ys te m is fairand e qu itable and s e e m s to work we ll. A llinm ate s
withu rge nt c
are ne e d s are s e e n in atim e ly m anne r.
Handbook
D e ntalc
are is not ad d re s s e d in the O ffe nd e r H and book and O rientation M anu al. T his om iss ion
s hou ld be ad d re s s e d im m e d iate ly. I was told that inm ate s we re inform e d abou t the d e ntalprogram
and how to ac
c
ess c
are at the re c
e ption intake s c
re e ninge xam ination. T his is re ally not ad e qu ate .
Recommendations:
1. Ins u re that inform ation abou t the d e ntalprogram and how to ac
c
e s s d e ntalc
are is inc
lu d e d
in the O ffe nd e rH and book and O rientation M anu alat Logan C C .

T he e xistingpolic
y and proc
e d u re m anu alis old and ou td ate d and d oe s not ad d re s s the c
u rre nt
s tate of how the c
linicis m anage d and ru n, nor d oe s it fu lly ad d re s s the are as c
onc
e rne d with
m anaging and ru nning a s u c
c
e s s fu l c
linic
. T he pre s e nt m anu al ad d re s s e s tre atm e nt plans ,
sc
he d u lingtre atm e nt, m e d ic
ations , d e ntalc
are forinm ate s (d ire c
tly ou t ofA d m inistrative
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onalC enter
P age 35
D ire c
tive ), c
opay for offe nd e rs , s e c
u rity of m e d ic
ation and ne e d le s , ins tru m e nts , etc
., infe c
tion
c
ontrol(from 1993), jobd e s c
ription ford e ntist and d e ntalas s istant. It d oe s apoorjobofd e fining
and d ire c
tingthe m anage m e nt and ru nningofthe d e ntalprogram at Logan C C .
Recommendations:
1. T hat the d e ntalprogram at Logan C C d e ve lopad e taile d , thorou ghand ac
c
u rate polic
y and
proc
e d u re m anu althat d e fine s how allas pe c
ts of the d e ntalprogram are to be ru n and
m anage d . O nc
e d e ve lope d , it s hou ld be u pd ate d on are gu larbas is and as ne e d e d forne w
polic
ies and proc
e d u re s
Failed Appointments
17.5% . T his is s om e what highand s hou ld be ad d re s s e d . W he n as ke d , the s taffre late d that it is
ofte n d iffic
u lt forinm ate s to be re le as e d from the hou s ingu nits to c
om e to the irappointm e nt. O r
the re m ay be othe rprogram ac
tivities to pre ve nt the m from c
om ingto the appointm e nt. T he staff
d id not fe e lit was apu rpos e fu lno-s how on the inm ate s part. A re fu s alform is s igne d ifthe inm ate
d oe s not want to ke e pthe irappointm e nt.
Recommendations:
1. T he d e ntals taffi
nve s tigate to find the re as ons forfaile d appointm e nts and the n pu t in plac
e
c
orre c
tive ac
tion to lowe r the rate to a m ore ac
c
e ptable le ve l. A c
ontinu ing qu ality
im prove m e nt stu d y wou ld be agood m e thod ologic
alte c
hniqu e .
Specialists
D r. Fre d e ric
k C raig, orals u rge on, is available on an as ne e d e d bas is, u s u ally onc
e am onth. Logan
C C re c
e ntly c
hange d m iss ions to afe m ale ins titu tion. D r. C raighad not ye t be e n to the ins titu tion.
H e was s c
he d u le d for the ne ar fu tu re to s e e agrou p ofpatients . A re view ofthe s e c
ons u ltation
re qu e s ts re ve ale d that the y we re allre fe rre d to the orals u rge on forappropriate re as ons . A llwe re
ford iffic
u lt e xtrac
tions and re m ovalofwisd om tee ththat we re be yond the s c
ope ofthe d e ntists
prac
tic
e . D r. C raigis als o u s e d by s e ve ralothe r ID O C ins titu tions for orals u rge ry. P athology
s e rvic
e s willbe the s am e as form e d ic
alpathology. T he y willgive the s pe c
im e n to the appropriate
m e d ic
alpe rs on forproc
e s s ing.
Recommendations:
1. I Su gge st that the y m aintain an orals u rge ry logto inc
lu d e patients to be s e e n, the d ate s e e n,
and what the y we re tre ate d forand any pos t-s u rgic
alc
om plic
ations .
Dental CQI
T he d e ntalprogram only c
ontribu te s m onthly d e ntals tatistic
s to the C Q I c
om m itte e . N o C Q I stu d y
was in plac
e at the tim e ofthis re view. I s hare d s e ve ralare as whe re am e aningfu lC Q I s tu d y c
ou ld
be initiate d and how it s hou ld proc
e e d . A re c
e nt m iss ion c
hange at Logan C C allowe d only two
m onths ofm inu te s to be re viewe d .
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L ogan C orrec ti
onalC enter
P age 36
Recommendations:
1. T hat are as of program we akne s s or c
onc
e rns be id e ntified and m e aningfu l qu ality
im prove m e nt s tu d ies be initiate d that le ad to ac
tions that willim prove the program in thos e
are as .

W e re viewe d m inu te s that re fle c
t C Q I ac
tivities , bu t nowhe re in the m inu te s is the re any e ffort to
im prove the qu ality of s e rvic
e s . T he m inu te s c
ons ist of d atac
olle c
te d on anu m be r of s e rvic
es.
T he s e s e rvic
e s inc
lu d e offs ite s e rvic
e s /hos pitaland E R trips , tre atm e nt protoc
olre view, m ortality
re views , ne w and d e laye d d iagnos is re views , infe c
tion c
ontrolinc
id e nt re ports , aM R SA re port,
he patitis C inform ation, H IV inform ation, e m e rge nc
y d rills , the m os t re c
e nt ofwhic
hwas in Ju ne
2013, s afe ty and s anitation ins pe c
tion re ports , labre d raw rate s , the volu m e of e m ploye e u s e of
he alths e rvic
e s , ve nd or inju ries , qu ality c
ontrolac
tivities , patient s atisfac
tion, c
hronicc
linicd ata
and m e ntalhe althd ata. A llofthis is re porte d bu t the re was no d oc
u m e nte d d isc
u s s ion, analys is or
any e fforts to im prove qu ality. T his is not an e ffe c
tive C Q I program .
A pril2014
L ogan C orrec ti
onalC enter
P age 37
Recommendations
1. Se e k approvaland fillthe D ire c
torofN u rs ingpos ition as s oon as pos s ible .
1. Im ple m e nt anu rs e c
alls ys te m fore ac
hinfirm ary patient.
1. T he re s hou ld be as pac
e on the intake phys ic
alform to d oc
u m e nt the bre as t e xam .
2. T he re m u s t be am ore appropriate s pac
e whe re anu rs e c
an inte rview apatient forthe nu rs e
sc
re e n or anu rs e prac
titione r for the history and phys ic
alin whic
h the re is no au d itory
d istu rbanc
e.
3. A s ys te m m u s t be s e t u pto ins u re that appropriate and tim e ly follow u pfrom the re c
e ption
proc
e s s d oe s oc
c
u r.
Medical Records:
1. T he re s hou ld be no loos e filingins id e the he althre c
ord s . M e d ic
alre c
ord s s taffs hou ld ad opt
atou c
hit onc
e philos ophy whe n it c
om e s to filingloos e d oc
u m e nts .
2. H e alths e rvic
e re qu e s t form s s hou ld be file d in the he althre c
ord s .
Nursing Sick Call:
1. D e ve lopand im ple m e nt aplan foran allR N s ic
kc
allproc
ess.
2. In the X -hou s e , d e ve lopand im ple m e nt aplan to c
ond u c
t ale gitim ate s ic
kc
alle nc
ou nte r,
inc
lu d ing liste ning to the patient c
om plaint, c
olle c
ting a history and obje c
tive d ata,
pe rform ingaphys ic
ale xam ination whe n re qu ire d , m akingan as s e s s m e nt and form u lating
aplan oftre atm e nt, rathe rthan the c
u rre nt prac
tic
e oftalkingto the patient throu ghasolid
s te e ld oorand bas ingany tre atm e nt on the c
onve rs ation only.
3. P e rO ffic
e ofH e althSe rvic
e s polic
y, as s u re alls ic
kc
alle nc
ou nte rs are d oc
u m e nte d in the
m e d ic
alre c
ord in the Su bje c
tive -O bje c
tive -A s s e s s m e nt-P lan (SO A P )s tyle .
4. D e ve lopand im ple m e nt aplan to as s u re the O ffic
e ofH e althSe rvic
e s approve d , preprinte d
tre atm e nt protoc
olform s are u s e d at e ac
hs ic
kc
alle nc
ou nte r.
5. D e ve lop and im ple m e nt a plan of e d u c
ation for all nu rs ings taff to ad d re s s ne gative
attitu d inaliss u e s toward inm ate s , partic
u larly fe m ale inm ate s .
6. D e ve lop, im ple m e nt and m aintain logs fors ic
kc
all, infirm ary and s e gre gation.
7. D e ve lop and im ple m e nt a plan to ins u re s e gre gation d aily we llne s s c
he c
ks and the
we e kly nu rs e prac
titione rrou nd s are d oc
u m e nte d in the s e gre gation logand in the inm ate
s pe c
ificm e d ic
alre c
ord ifany tre atm e nt is provide d .
8. D e ve lopand im ple m e nt aplan to c
ond u c
t the d aily s e gre gation we llne s s c
he c
ks be twe e n
the hou rs of7:00a.m . and 11:00p.m .
1. C ons ide r as s igningthe M e d ic
alD ire c
torto the poorly c
ontrolle d c
hronicd ise as e patients ,
as this is c
le arly one ofhis s tre ngths .
A pril2014
L ogan C orrec ti
onalC enter
P age 38
2. T he re s hou ld be ac
om pre he ns ive trac
kingtoolto m onitorim portant ind ic
ators forthis atrisk popu lation. T his tools hou ld be u s e d to ide ntify are as of poor pe rform anc
e in the
program to target inte rve ntions to im prove qu ality.
3. T he c
hronicd ise as e nu rs e s hou ld rare ly if e ve r be pu lle d to othe r d u ties . T his pos ition
s hou ld be fille d withac
are fu lly c
hos e n ind ivid u alto ac
tive ly trac
k this at-risk popu lation.
c
ontrolrathe rthan the c
ale nd ar
m onthand allc
hronicd ise as e s s hou ld be ad d re s s e d at e ac
hc
hronicc
are c
linicvisit. T he s e
are s tate wide polic
y iss u e s .
5. P atients with ac
tive wom e n
s he alth iss u e s s hou ld be trac
ke d in an organize d m anne r,
pe rhaps in the c
6. P atients withH IV infe c
tion s hou ld have ye arly c
e rvic
alc
anc
e rs c
re e ning.
1. A s ys te m ofnu rs ings u pe rvision withfe e d bac
k m u s t oc
c
u rs o that e rrors withre gard to the
ad e qu ac
y of the as s e s s m e nt or the appropriate ne s s of the c
linic
al d e c
ision m akingare
re d u c
e d s u bs tantially.
2. T he ad m inistrator s hou ld d e ve lop a logthat c
an be u s e d to trac
k u ns c
s e rvic
e s . T he log s hou ld have the tim e and d ate , patient ide ntifiers , the pre s e nting
c
om plaint, what the d ispos ition was in te rm s ofbe ings e nt offs ite and whe the rthe re ports
from the offs ite s e rvic
e are re trieve d .
3. T he re s hou ld be am e thod to trac
k the follow-u pvisits withthe prim ary c
are c
linic
ian and
whe the rthe y d oc
u m e nte d the d isc
u s s ion withthe patient ofthe find ings and plan bas e d on
the offs ite s e rvic
e re ports .
1. T he policy s hou ld re qu ire that patients re tu rningfrom s c
e s are brou ght
throu ghthe c
linicare awhe re anu rs e re c
e ive s the pape rwork, inte rviews the patient and
u ltim ate ly ins u re s that atim e ly follow-u pvisit withthe prim ary c
are c
linician d oe s oc
c
u r.
Infirmary Care:
1. M ore be d s pac
e is ne e d e d forthe infirm ary.
2. R ethinkingthe phys ic
alplant to c
re ate am ore the rape u tic
, le s s c
haotice nvironm e nt wou ld
be be ne fic
ial.
3. D e ve lopand im ple m e nt aplan to ins u re 24/7R N s taffing.
4. Im ple m e nt anu rs e c
alls ys te m forallinfirm ary patients .
5. D e ve lop, im ple m e nt and m aintain aplan for organization of infirm ary m e d ic
al re c
ord s
inc
lu d ingbu t not lim ite d to:
a. the u s e ofone infirm ary re c
ord
b. pe rm ane nt filingofalld oc
u m e nts in the re c
ord
c
. c
hronologic
alfilingofalld oc
u m e ntation.
6. D e ve lopand im ple m e nt aplan ofe d u c
ation fors taffinc
lu d ingbu t not lim ite d to:
a. pe rID O C O ffic
e ofH e althSe rvic
e s polic
y, d oc
u m e ntation to be provide d in the
Su bje c
tive -O bje c
tive -A s s e s s m e nt-P lan (SO A P )form at
b. alld oc
u m e ntation to be provide d c
hronologic
ally as to d ate and tim e
A pril2014
L ogan C orrec ti
onalC enter
P age 39
c
. d oc
u m e ntation ofvitals igns as ord e re d by the phys ic
ian
d . phys ic
ian and nu rs ingad m iss ion and d isc
harge d oc
u m e ntation re qu ire d for all
infirm ary patients .
Infection Control:
1. D e ve lopand im ple m e nt apost-d e s c
ription foran infe c
tion c
ontrolnu rs e .
2. A s s ign as pe c
ificR N to the re s pons ibilities ofinfe c
tion c
ontrol.
3. D e ve lop, im ple m e nt and m aintain aplan to as s u re the prope r lau nd e ringof infirm ary
CQI:
1. T he s taffs hou ld be traine d in C Q I m e thod ology, s pe c
ific
ally withre gard to how to perform
s tu d ies , how to ide ntify s u bthre s hold pe rform anc
e , how to analyz e the d atain ord e r to
d e te rm ine the c
au s e s ofs u bthre s hold pe rform anc
e , and the n how to d e ve lopim prove m e nt
s trate gies bas e d on the ide ntified c
au s e s and finally how to re s tu d y to d ete rm ine whe the r
the im prove m e nt s trate gy had the re qu ire d e ffe c
t.
c
olle c
tion.
s trate gies .
A pril2014
L ogan C orrec ti
onalC enter
P age 40

Patient Number
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
Offsite Services/Emergencies:
Patient Number
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
P atient #1
P atient #2
P atient #3
P atient #4
Onsite Service/Emergency:
Patient Number
Name
Inmate ID
[redacted]
[redacted]
[redacted]
P atient #1
P atient #2
P atient #3
Patient Number
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
A pril2014
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
L ogan C orrec ti
onalC enter
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P age 41
P atient #10
P atient #11
P atient #12
P atient #13
P atient #14
P atient #15
P atient #16
P atient #17
P atient #18
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Womens Health:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Infirmary:
Patient Number
P atient #1
Name
[redacted]
Inmate ID
[redacted]
Responses to Attorney Letter:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
P atient #11
P atient #12
P atient #13
A pril2014
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
L ogan C orrec ti
onalC enter
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P age 42
Illinois River Correctional Center (IRCC)

Report
April 17 & 18 and May 5 & 6, 2014
Prepared by the Medical Oversight Committee

Ron Shansky, MD
Karen Saylor, MD
Larry Hewitt, RN
Karl Meyer, DDS
Contents
Overview....................................................................................................................................3
Findings .....................................................................................................................................4
C linicSpac
e and Sanitation .....................................................................................................6
Intras ys te m T rans fe rs ...............................................................................................................6
M e d ic
alR e c
ord s ......................................................................................................................8
N u rs ingSic
k C all.....................................................................................................................8
C hronicD ise as e M anage m e nt..................................................................................................9
P harm ac
y/M e d ic
Laboratory .............................................................................................................................17
U ns c
e s ............................................................................................... 18
Sc
e s ....................................................................................................18
U ns c
he d u le d O ffs ite and O ns ite V isits .................................................................................. 19
Infirm ary C are .......................................................................................................................20
Infe c
tion C ontrol...................................................................................................................23
Inm ate s Inte rviews .................................................................................................................24
D e ntalP rogram ......................................................................................................................25
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 2
Overview
O n A pril16-18, and M ay 5-6, 2014, we visite d the Illinois R ive rC orre c
tionalIns titu tion (IR C C )
in C anton, Illinois. T his was ou rfirs t s ite visit to IR C C and this re port d e s c
ribe s ou rfind ings and
re c
om m e nd ations . D u ringthis visit, we :
al
als e rvic
e s are a
are s taff
u m e nts
W e thank W ard e n Gre gGos s e tt and his s taffforthe iras s istanc

e and c
oope ration in c
ond u c
ting
the re view.
Executive Summary
T he Illinois R ive rC orre c
tionalC e nte rope ne d as ne w c
ons tru c
tion in O c
tobe r1989, and has be e n
we llm aintaine d s inc
e that tim e .
IR C C is a m e d iu m -s e c
u rity prison that hou s e s m ale offe nd e rs . T he c
u rre nt popu lation is
approxim ate ly 2081inm ate s . T he ins titu tion is not are c
e ption c
e nte rbu t has an infirm ary and an
ou tpatient m e ntalhe althm iss ion.
T he fac
ility ge ts abou t 25 intake s pe r we e k, withW e d ne s d ay be ingthe bigge s t intake d ay. Sic
k
c
allis m ilitary s tyle withas ign-u ps he e t in e ac
hu nit. P atients have u ntil6a.m . to s ign u pfors ic
k
c
alland willbe s e e n by the nu rs e (R N orLP N )that d ay. T he offic
e rc
olle c
ts the s ic
kc
alls ign-u p
s he e t at 6a.m .
T he fac
ility was s u ffe ringfrom ale ad e rs hipc
risis. T he H C U A was on am u ltiye arm ilitary le ave
ofabs e nc
e and was not e xpe c
te d bac
k u ntilO c
tobe rofthis ye ar. B oththe M e d ic
alD ire c
torand
the s taffphys ic
ian pos ition we re vac
ant at the tim e ofou rvisit. T hos e hou rs we re partially c
ove re d
by prn (as ne e d e d )provide rs ;at the tim e ofou rvisit, IR C C was getting2.5 d ays ofphys ic
ian
c
ove rage pe rwe e k. T he re was anu rs e prac
titione rc
om ingone d ay pe rwe e k u ntilthe we e k prior
to ou rvisit, whe n s he got afu ll-tim e jobe ls e whe re . T he y have hire d afu ll-tim e nu rs e prac
titione r
who was ye t to re c
e ive training. It was not known whe n the y c
ou ld e xpe c
t he rto be gin work. T he
ac
tingM e d ic
alD ire c
tor was c
om ingfrom anothe r fac
ility to provide one d ay of c
ove rage pe r
we e k.
Sinc
e the provide r vac
anc
ies e arlier this ye ar, the re has be e n as ignific
ant bac
klogin c
hronic
d ise as e c
linic
s . T he bac
klogis e xac
e rbate d by the prac
tic
e ofad d re s s ingonly one proble m at a
tim e d u ringac
hronicc
are c
linicvisit. W e note d m u ltiple c
as e s whe re in patients we re s e e n fora
partic
u lard ise as e c
linicwithe vid e nc
e ofpoorc
ontrolofanothe rd ise as e bu t the othe rd ise as e
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 3
was not ad d re s s e d . In ou ropinion, allc

hc
hronicc
are
c
linicvisit.
T he m e d ic
alre c
ord s d ire c
tor is highly organize d and e ffic
ient. H owe ve r, M A R s we re ofte n not
file d into the re c
ord s tim e ly, and s om e c
ou ld not be loc
ate d whe n we re qu e s te d the m . T his m ake s
it d iffic
u lt to im pos s ible forprovide rs to obje c
tive ly e valu ate m e d ic
ation c
om plianc
e . In ad d ition,
the re is e vid e ntly no s ys te m in plac
e to notify provid e rs ofm e d ic
ation nonc
om plianc
e . R athe r, it
is u pto the d isc
re tion ofthe ind ivid u alnu rs e who id e ntifies alaps e in c
ontinu ity whe the rto notify
the pre s c
ribe rornot.
W ec
am e ac
ros s s e ve ralhighly proble m aticc
as e s d u ringthe c
ou rs e ofou rre view that re s u lte d in
ac
tu alharm to patients (s e e C ard iovas c
u larC linic
, Infirm ary C are and M ortality R e views ), s om e
ofwhic
hwe re u nd e rthe c
are ofthe form e rM e d ic
alD ire c
torwho we u nd e rs tand no longe rworks
forW e xford . H owe ve r, the re we re s e ve ralc
as e s ofm ism anage m e nt by provide rs s tillworkingin
the s ys te m . T his highlights the broad e riss u e oflac
k ofc
linic
alove rs ight bothloc
ally at the fac
ility
give n the vac
ant M e d ic
alD ire c
torpos ition, and c
e ntrally by W e xford .
Sic
kc
allis c
ond u c
te d by non-re giste re d nu rs ing(R N )s taffand is lac
kingin qu ality. Se gre gation
s ic
kc
all, als o c
ond u c
te d by non-R N s taff, is not s ic
kc
all bu t ac
e lls id e triage , be c
au s e the
e nc
ou nte r is c
ond u c
te d throu gh as olid s te e ld oor and tre atm e nt is bas e d only on the patient
s
s u bje c
tive c
om plaints withou t the be ne fit ofany phys ic
Inm ate porte rs workingthe H e althC are U nit have not be e n appropriate ly traine d in infe c
tiou s and
c
om m u nic
able d ise as e s , blood -borne pathoge ns , bod ily flu id c
le an-u p, infirm ary room , be d s and
fu rnitu re c
le aningand the appropriate s anitizingofinfirm ary be d d ingand line ns .
T he Intras ys te m proc
e s s re s u lts in id e ntified proble m s not be ingad d re s s e d tim e ly or in s om e
ins tanc
e s , e xistingproble m s are not be ingide ntified .
T he re are s ignific
ant proble m s with ad e qu ate and tim e ly follow-u p for patients s e nt offs ite for
sc
es.
T he le ad e rs hipofthe C Q I program d o not have ad e qu ate trainingin C Q I m e thod ology. T he re fore ,
the re is no e vid e nc
e that the program is u tilize d to im prove the qu ality ofc
are at IR C C .
Findings
A t the tim e ofou rvisit, the H e althC are U nit A d m inistratorhad be e n on m ilitary le ave foraye ar
and ahalf. T his m ilitary le ave was d u e to e nd in approxim ate ly s ix m onths . D u ringthe le ave , the
D ire c
torofN u rs ingals o fu nc
tione d as the H e althC are U nit A d m inistrator. T he D ire c
torofN u rs ing
had be e n in he rpos ition forthre e ye ars . T he M e d ic
alD ire c
torpos ition has be e n vac
ant s inc
e the
e nd of Janu ary. T he re is als o a vac
ant nu rs e prac
titione r pos ition. T he program d oe s re c
e ive
approxim ate ly two d ays pe rwe e k fill-in from the M e d ic
alD ire c
torat the E ast M oline
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 4
C orre c
tional Fac
ility and an ad d itional two d ays pe r we e k from a fill-in nu rs e prac
titione r.
A lthou ghthe D ire c
torofN u rs ingappe ars to be ve ry hard working, it is e xtre m e ly d iffic
u lt to fill
two fu ll-tim e le ad e rs hippos itions . W iththe ad d itionalabs e nc
e ofboththe M e d ic
alD ire c
torand
c
linic
alhou rs , the re appe ar to be s ignific
ant d e lays withre gard to c
hronicc
are visits and othe r
c
linic
alas s e s s m e nts . It d oe s not appe arthat the re is ad e qu ate c
linic
alove rs ight.
Position
M e d ic
alD ire c
tor
StaffP hys ic
ian
N u rs e P rac
titione r
D ire c
torofN u rs ing
C orre c
tions N u rs e I
C orre c
tions N u rs e II
Lic
e ns e d P rac
tic
alN u rs e s
H e althInform ation A s s oc
iate
P hle botom ist
R ad iology T e c
hnic
ian
P harm ac
y Tec
hnic
ian
P harm ac
y Tec
hnic
ian
O ffic
e A s s oc
iate
StaffA s s istant
C hiefD e ntist
StaffD e ntist
D e ntalH ygienist
O ptom e try
P hys ic
alT he rapist
P hys ic
Total
Current FTE
1.0
Filled
0
Vacant
1.0
State/Cont.
C ontrac
t
1.0
1.0
0
1.0
C ontrac
t
State
1.0
1.0
1.0
M ilitary
LO A -2
yrs .
0
8.0
12.0
7.0
12.0
1.0
0
C ontrac
t
C ontrac
t
1.0
1.0
C ontrac
t
C ontrac
t
0.30
2.0
0.30
2.0
0
0
C ontrac
t
C ontrac
t
1.0
1.0
State
1.0
1.0
C ontrac
t
2.0
0.5
0.20
2.0
0.5
0.20
0
0
0
C ontrac
t
C ontrac
t
C ontrac
t
32
29
C ontrac
t
T he re are le ad e rs hip iss u e s , in that the M e d ic

alD ire c
tor pos ition is vac
ant, and the H e althC are
U nit A d m inistrator(H C U A )has be e n on am ilitary le ave ofabs e nc
e forapproxim ate ly two ye ars .
T he m e d ic
alc
ontrac
torD ire c
torofN u rs ing(D O N )e m ploye e is m anagingthe he althc
are program .
O the rvac
anc
ies are m inim al.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 5
A re view ofm e d ic
als taffc
re d e ntialingand lic
e ns u re ind ic
ate s taffwho have be e n appropriate ly
traine d , are c
u rre ntly lic
e ns e d and workingwithin the irre s pe c
tive s c
ope s ofprac
tic
e . W hile the re
have be e n s ignific
ant nu rs ingvac
anc
ies at othe rfac
ilities , s e ve n ofe ight R N pos itions and 12of
12LP N pos itions are fille d .
O fc
onc
e rn, withthe M e d ic
alD ire c
tor vac
anc
y and the long-te rm H C U A le ave ofabs e nc
e , the
D O N re pre s e nts the only he althc
are le ad e rs hipforthis large fac
ility withabu s y he althc
are u nit,
ye t s he has be e n as s igne d by the m e d ic
al c
ontrac
tor as the s ite m anage r. T he s ite m anage r
re s pons ibilities are s ignific
ant and s u bs tantially take away from he rability to foc
u s on and m anage
the ne e d s ofthe he althc
are u nit.

Illinois R ive r C orre c
tionalC e nte rope ne d as ne w c
ons tru c
tion in O c
tobe r 1989. Sinc
e that tim e ,
the fac
ility has be e n we llm aintaine d . T he he althc
are u nit (H C U )is alarge , we ll-lighte d and we ll
m aintaine d bu ild ing. T he re is am od e rate s ize d inm ate waitingare ane arthe e ntranc
e , as we llas a
m e d ic
ation ad m inistration wind ow and offic
e r
s s tation. Fu rthe r in the H C U is the ou tpatient
nu rs ings tation, rad iology s u ite , d e ntalc
linic
, alarge m e d ic
ation/storage room , thre e we ll-e qu ippe d
e xam ination room s , an optom e try c
linic
, am e d ic
alre c
ord s d e partm e nt, alarge we ll-e qu ippe d
u rge nt c
are room , a15-be d infirm ary and m u ltiple offic
e are as .
Intrasystem Transfers
W e re viewe d 15 re c
ord s ofpatients who e nte re d the fac
ility within the prior thre e m onths . W e
atte m pte d to s e le c
t re c
ord s ofpe ople withknown m e d ic
alproble m s . In e ight ofthe 15re c
ord s , we
id e ntified s ignific
ant proble m s . T he proble m s inc
lu d e d lac
k ofid e ntific
ation ofaproble m at the
tim e ofthe intras ys te m trans fe r as we llas proble m s withtim e ly follow u p for ide ntified s e rvic
e
ne e d s .
Patient #1
T his is a53-ye ar-old who arrive d at Illinois R ive rC orre c
tionalC e nte ron 2/26/14. H e had e nte re d
the d e partm e nt in O c
tobe r 2013. A t the tim e of his intake , he was ide ntified as havingc
hronic
obs tru c
tive pu lm onary d ise as e , ac
rom e galy, obs tru c
tive s le e p apne a, hype rte ns ion, atrial
fibrillation, ps orias is and ahistory ofprior he art attac
ks as we llas c
onge s tive he art failu re . O n
intake , his blood pre s s u re was e le vate d at 142/98. H e had be e n on C ou m ad in as atre atm e nt forhis
atrialfibrillation bu t the m e d ic
ation had be e n d isc
ontinu e d at his re qu e s t. A fte rhe arrive d at Illinois
R ive rC orre c
tionalC e nte r, he was re s tarte d on the C ou m ad in on 3/5/14. T his patient was s e e n for
his hype rte ns ion c
hronicc
are c
linicon 3/19;howe ve r, no othe rc
hronicproble m s , ofwhic
hhe had
s e ve ral, we re ad d re s s e d .
Patient #2
T his is a20-ye ar-old patient withas thm awho e nte re d the s ys te m on 1/30/14and arrive d at Illinois
R ive r C orre c
tionalC e nte r on 2/26. H e was re c
e ivingboth as teroid inhale r and abe taagonist.
A lthou ghhe arrive d at Illinois R ive rin Fe bru ary, he has s tillnot be e n s e e n in the as thm ac
hronic
c
are c
linic
.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 6
Patient #3
T his is 40-ye ar-old withhype rte ns ion and d iabe te s on ins u lin. H e als o has gou t, althou ghthe gou t
is not liste d on the proble m list. O n 4/17/14, he was s e e n ford iabe te s and hype rte ns ion bu t the re
was no e ffort to follow u phis gou t. O n 4/6, he appe are d to have aflare -u pofhis gou t.
Patient #4
T his is a63-ye ar-old who e nte re d the s ys te m on 1/24/14and arrive d at Illinois R ive rC orre c
tional
C e nte r on 2/19. A t the tim e of e ntry, he was id e ntified as havingd iabe te s type 2 as we ll as
hype rte ns ion alongwithc
hronickid ne y d ise as e . A lthou ghhe arrive d at Illinois R ive ron 2/19, he
d id not have his c
hronicc
are c
linicu ntilA prilofthis ye ar. A t the tim e ofthe c
hronicc
are visit,
his blood pre s s u re was s ignific
antly e le vate d at 150/92 and ye t the hype rte ns ion was liste d as
c
ons iste nt withgood c
ontrol. T his is c
le arly an e rrorwhic
hre s u lts in ad e c
ision not to c
hange the
re gim e n orpe rform re gu larblood pre s s u re m onitoring.
Patient #5
T his is a47-ye ar-old who e nte re d the s ys te m on 2/6/14and arrive d at Illinois R ive rC orre c
tional
C e nte ron 2/21. H e was id e ntified as havinghype rte ns ion, ahistory ofam otorve hic
le ac
c
id e nt
and ahistory ofalc
oholabu s e . O n ad m iss ion, his blood pre s s u re was 160/96and ye t his c
hronic
c
linicvisit to ad d re s s the hype rte ns ion was not sc
he d u le d for m ore than am onth late r. T his is
d e s pite the fac
t that the blood pre s s u re was e le vate d .
Patient #6
T his patient e nte re d the s ys te m on 2/19/13 and arrive d at Illinois R ive r C orre c
tionalC e nte r on
2/21/14. H e is 52ye ars old withtype 2d iabe te s , hype rte ns ion, as thm aand hype rlipid e m ia. A t the
tim e he e nte re d , his blood pre s s u re was 146/98. H e had d e ve lope d aras h. A t s ic
kc
allon 2/26/14,
his blood pre s s u re re m aine d e le vate d at 162/106. T he nu rs e re c
om m e nd e d c
he c
kingthe blood
pre s s u re d aily forfive d ays . T he ne xt e ve ning, the patient pre s e nte d withtre m ors and the phys ic
ian
was c
alle d and the patient was plac
e d in the infirm ary. T he patient was s e e n the followingd ay by
the phys ic
ian as s istant and he was d isc
harge d to the hou s ingu nit. O n 3/18, his firs t c
hronicc
are
c
linicoc
c
u rre d , bu t only the he patitis C and the d iabe te s we re m onitore d . N e ithe rthe as thm a, the
hype rlipid e m iaorthe hype rte ns ion we re ad d re s s e d .
Patient #7
T his patient e nte red the s ys te m on 1/24/14and arrive d at Illinois R ive rC orre c
tionalC e nte ron 2/7.
H e is a44-ye ar-old withhype rte ns ion and asthm aas we llas m e ntalhe althproble m s . O n 2/7, at his
c
hronicc
are c
linic
, antihype rte ns ive s and as thm am e d ic
ations we re ord e red . O n 4/4, the patient
re fu s e d the m e d ic
ations and as are s u lt he was d isc
harge d from the c
hronicc
are program . T he re is
no d oc
u m e ntation ofc
ou ns e lingby aphys ic
ian re gard ingthe risks and be ne fits .
Patient #8
T his patient e nte re d the s ys te m on 1/30/14 and arrive d at Illinois R ive r C orre c
tionalC e nte r on
2/19/14. T his is a45-ye ar-old with ahistory of alc
oholabu s e , hype rte ns ion, abe low the kne e
am pu tation on the le ft s id e , obs tru c
tive s le e papne aand right lu ngnod u le s . H e had ac
ou ghand a
fe ve rof101.8, althou ghthe x-ray was norm al. H e was plac
e d in the infirm ary and d iagnos e d with
influ e nz atype A . H e was late r s e e n in the c
hronicc
are c
linicon 3/13. H is blood pre s s u re was
e le vate d and this was c
orre c
tly as s e s s e d . E ight d ays late r, he pre s e nte d to s ic
kc
allwitha
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 7
c
om plaint oftarry s tools and abd om inalpain. A n LP N d oc
u m e nte d are c
tale xam . LP N s ge ne rally
d o not have e ithe r appropriate trainingor e xpe rienc
e to d o this e xam . A phys ic
ian s hou ld have
be e n c
alle d and e ithe ran R N orP A s hou ld have be e n involve d .
Medical Records
M any c
harts we re in ne e d ofthinning. P roble m s lists we re ofte n not c
u rre nt and we re bu ried u nd e r
the ord er s he e ts . M A R s we re not file d tim e ly into the re c
ord s, whic
h m ake s it im pos s ible for
provide rs to e valu ate patients m e d ic
ation c
om plianc
e.
W e le arne d that only the re c
ord s of patients who parole are au tom atic
ally re qu e s te d (by the
re c
ord s offic
e )u pon the ir re tu rn to the s ys te m . For patients who d isc
harge (i.e ., c
om ple te the ir
s e nte nc
e ), it is u p to the re c
e ivingins titu tion to re qu e s t the re c
ord ;the y are not au tom atic
ally
s u m m one d by the re c
ord s offic
e . T his fac
t was re le vant in the c
as e ofapatient withH IV infe c
tion
whos e s tatu s we nt u nre c
ognize d fors e ve ralm onths afte rhe was re le as e d and re inc
arc
e rate d (s e e
patient [redacted] in the H IV s e c
tion ofthis re port). T his willpre s u m ably be am oot point whe n
the e le c
tronicre c
ord goe s live , bu t it is u nc
le arwhe n this willbe and how m u c
hofthe old re c
ord s
willbe u pload e d to the e le c
tronicform at.
Nursing Sick Call

T he fac
ility u s e s an arm y s tyle or ope n s ic
kc
alls ys te m for ge ne ralpopu lation inm ate s . T his
m e ans the re are s ic
kc
alls ign-u p s he e ts in e ac
h hou s ingu nit. Inm ate s are inform e d that ifthe y
s ign-u pfors ic
kc
allby 6:00a.m ., the y willbe take n to the he althc
are u nit (H C U )and e valu ate d
that s am e d ay. Inm ate s c
ou ld be e valu ate d by e ithe raR e giste re d N u rs e (R N )orLic
e ns e d P rac
tic
al
N u rs e (LP N ) who wou ld u s e approve d D e partm e nt of C orre c
tions O ffic
es
tre atm e nt protoc
ols .
Inm ate s in s e gre gation s tatu s are offe re d s ic
kc
alld aily, and the s ic
kc
all is c
ond u c
te d in the
s e gre gation u nit by e ithe raR N orLP N . T he s ic
kc
alle nc
ou nte r, in ac
tu ality, is afac
e -to-fac
e
triage , in that the nu rs e liste ns to the inm ate
sc
om plaint throu ghthe solid s te e lc
e lld oor. T he nu rs e
bas e s tre atm e nt orre fe rralon the inm ate
s s u bje c
tive c
om m e nts . V e ry rare ly d oe s the nu rs e re qu e s t
the inm ate
s c
e lld oorbe ope ne d orto re m ove the inm ate from his c
e ll. Ifthe nu rs e d oe s re qu e s t
that the inm ate be brou ght ou t ofhis c
e llfor fu rthe r as s e s s m e nt, the only room available is the
s e gre gation Lieu te nant
s offic
e , whic
h is not e qu ippe d as an e xam ination room . A s are s u lt, in
s e gre gation, nu rs e s ic
kc
allplans oftre atm e nt are form u late d withou t the be ne fit ofathorou gh
as s e s s m e nt whic
hm ay inc
lu d e the ne e d foraphys ic
ale xam ination.
A d d itionally, as ic
kc
alle nc
ou nte r throu gh as olid s te e ld oor provide s for no c
onfid e ntiality of
patient m e d ic
alinform ation.
Fifte e n ge ne ralpopu lation s ic
kc
allm e d ic
alre c
ord s we re re viewe d .
1. T hirte e n ofthe patients we re e valu ate d by aR N , and two we re e valu ate d by an LP N .
2. Fifte e n ofthe e nc
ou nte rs inc
lu d e d the u s e ofan approve d pre -printe d protoc
olform .
ou nte rs inc
lu d e d d u ration and good history ofthe c
om plaint.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 8
4. Fou rte e n ofthe 15e nc

ou nte rs inc
lu d e d vitals igns inc
lu d ingawe ight;two of14, e ve n
thou ghvitals igns we re c
olle c
te d , had no te m pe ratu re re c
ord e d , and ate m pe ratu re was
ind ic
ate d bas e d on the natu re ofthe patient c
om plaint.
ou nte rs inc
lu d e d ad oc
u m e nte d e xam ination.
6. T e n ofthe e nc
ou nte rs re s u lte d in are fe rralto the phys ic
ian orm id le ve lprovide r.

T he re are an u nknown nu m be rofinm ate s e nrolle d in the c
hronicd ise as e program . T he d istribu tion
in c
linic
s is as follows :
C ard iac
D iabe te s (90)
Ge ne ralM e d ic
ine (133)
H IV Infe c
tion/A ID S (15)
Live r(82)
T B Infe c
tion (8)
Labs are u s u ally d rawn tim e ly priorto the c

linic
s . C linic
s we re oc
c
u rringtim e ly u ntilthe re c
e nt
s taffvac
anc
ies . O nly one proble m at atim e is typic
ally ad d re s s e d d u ringac
hronicc
are c
linicvisit,
thou ghthe re we re afe w c
as e s in whic
ham u lti-c
linicform was u s e d . W e note d m u ltiple c
as e s
whe re in patients we re s e e n forapartic
u lard ise as e c
linicwithe vid e nc
e ofpoorc
ontrolofanothe r
d ise as e bu t the othe r d ise as e was not ad d re s s e d . In ou r opinion, allc
hronicd ise as e s s hou ld be
ad d re s s e d at e ac
hc
hronicc
are c
linicvisit.
For ke e p on pe rs on m e d ic
ations , the nu rs e s ge ne rate an M A R e ac
h m onth, u pon whic
h the y
write in the d ate that e ac
hm e d ic
ation was las t re c
e ive d by the patient. T he re is, the re fore , as ys te m
in plac
e to id e ntify whe n patients d on
t re qu e s t m e d ic
ation re fills tim e ly. H owe ve r, the re is no
m ec
hanism by whic
h this inform ation is rou te d bac
k to the provide rs . R athe r, patients
nonc
om plianc
e goe s u nad d re s s e d u ntilthe ne xt c
hronicc
are c
linic
. T his was c
onfirm e d withone
ofthe R N s on s ite who s tate d that whe n the y qu e s tione d the las t M e d ic
alD ire c
torabou t this, the y
we re told the c
om plianc
e iss u e c
ou ld wait u ntilthe ne xt c
hronicc
are c
linic
.
ord s of patients e nrolle d in the c
linicand fou nd opportu nities for
im prove m e nt in allc
as e s . R e c
ord re view re ve ale d age ne rald isinc
lination to ad d re s s e le vate d
blood pre s s u re re ad ings. W he n provide rs ord e re d blood pre s s u re c
he c
ks , the y ofte n d id not re view
the re ad ings. T he D O N c
onfirm e d that the re is no s ys te m in plac
e to rou te the blood pre s s u re
re ad ings bac
k to the ord e ringprovide r.
In the c
ou rs e ofre viewingre c
ord s forothe r c
linic
s , we ide ntified an ad d itionalc
as e whic
hwas
ve ry proble m atic(patient #1be low). T his patient was not e nrolle d in the c
ard iovas c
u larc
linicbu t
had ad e vas tatingad ve rs e ou tc
om e as are s u lt ofatrialfibrillation, and s o is d isc
u s s e d he re .
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 9
Patient #1
T his a26-ye ar-old m an who arrive d at IR C C on 11/16/12. H e re porte d ahistory ofs e izu re s and
atrialfibrillation withpriorc
ard iove rs ion, whic
hare d oc
u m e nte d on his proble m list.
O n 7/2/13, ac
od e 3was c
alle d to the u nit forbre athingproble m s and he art palpitations . T he nu rs e
note d his history ofatrialfibrillation withc
ard iove rs ion. A n E C G s howe d norm als inu s rhythm
witharate of83. H e als o c
om plaine d ofd izz ine s s and inc
re as e d u rination. T he nu rs e
s note state s
that the P A was on s ite to e valu ate the patient bu t the re was no note from the P A . A u rine s am ple
was obtaine d and the patient was tre ate d withB ac
trim .
O n 7/6, the patient was trans porte d to the H C U withs hortne s s ofbre athand palpitations . H is he art
rate was 98and blood pre s s u re 144/82. T he E C G showe d s inu s rhythm . T he d oc
torwas c
ons u lte d
and s he re c
om m e nd e d aps yc
hiatrice valu ation foranxiety and to follow u pas ne e d e d .
O n 7/11, the P A s aw the patient in follow u pofthe Ju ly 2nd e ve nt bu t ad d re s s e d only the u rinary
s ym ptom s and c
onc
lu d e d he had are s olve d U T I.
O n 11/1, he was s e e n by the LP N to re qu e s t that atrialfibrillationbe plac
e d on his nam e bad ge .
H e was re fe rre d to the phys ic
ian who told him that he had no e vid e nc
e ofatrialfibrillation.
O n 1/9/14, a c
od e 3 was c
alle d to the u nit for an e pisod e of u nre s pons ive ne s s with rapid
re s pirations . H is blood pre s s u re was 190/102and he art rate was 106. T he nu rs e note d his history
ofatrialfibrillation and ofs e izu re s . H is E C G s howe d s inu s rhythm . Fou rte e n m inu te s late rhe was
d esc
ribe d as ale rt and oriente d . H e was s e e n by the P A that d ay, who als o note d the history of
s e izu re s and ofatrialfibrillation withtwo priorc
ard iove rs ions . T he P A c
onc
lu d e d that the inc
id e nt
m ay have be e n as e izu re , plac
e d him in the infirm ary ove rnight, and s tarte d him on D ilantin.
O n 5/4, the patient was s e e n forc
he s t pain, s hortne s s ofbre athand le ft s id e d we akne s s withle ft
fac
iald roop. H e was s e nt ou t withac
onfirm e d s troke and re c
e ive d T P A . H e was s tillhos pitalize d
at the tim e ofou rre view on 5/6/14.
R e view ofpriorjailre c
ord s c
onfirm e d ahistory ofatrialfibrillation forwhic
hhe was c
ard iove rte d
in Ju ne 2012 and plac
e d on warfarin. H owe ve r, he d e ve lope d aright thighhe m atom ain A u gu s t
and the warfarin was he ld . It was not re s u m e d priorto his trans fe rto N R C .
Opinion:T his is atragicc
as e ofave ry you ngm an who s u ffe re d ad e vas tatinge ve nt whic
hwas
pre ve ntable withthe appropriate tre atm e nt (antic
oagu lation). T he patient re porte d his history of
atrialfibrillation and c
ard iove rs ion m u ltiple tim e s throu ghou t his s tay in ID O C , and this history
c
ou ld have be e n re ad ily valid ate d by m e d ic
als taffhad the y bothe re d to re view his jailre c
ord s .
Patient #2
T his is a58-ye ar-old m an withtype 2d iabe te s , hype rte ns ion, hype rlipid e m iaand c
oronary arte ry
d ise as e withhistory ofbypas s s u rge ry who arrive d at IR C C on 10/28/11.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 10
O n 5/9/13, he was s e e n in d iabe te s c

linic
. H is blood pre s s u re was 152/88, bu t was not ad d re s s e d .
ard iacc
linic
. H is blood pre s s u re was 164/82, whic
hwas rate d as fair.
T he d oc
tor note d , IM wants to work on d iet, and d id not ad ju s t his m e d ic
ations . Labs we re
ord ere d for10/25and afollow-u pvisit for11/1, as we llas we e kly blood pre s s u re c
he c
ks . T he s e
we re d oc
hart as :144/76, 156/90, 158/88, and 176/96. T he re is no e vid e nc
e that a
provide rre viewe d orre s pond e d to the s e in any way.
O n 9/9, he was s e e n in d iabe te s c
linic
. T he blood pre s s u re was 150/90 at this visit bu t was not
m e ntione d orad d re s s e d .
ard iacc
linic
. H is blood pre s s u re was 164/84and one ofhis m e d ic
ations
was inc
re as e d . A t this visit he s tate d that it fe e ls like s om e thingis m ovingin m y c
he s t.. T his is
not d e s c
ribe d fu rthe r. T he d oc
tor ord ere d a c
he s t x-ray, whic
h was d one on 11/4 and was
u nre m arkable . W he n s he s aw him bac
k at D SC on 11/15forthis, his blood pre s s u re was 146/82
bu t not m e ntione d .
T he m os t re c
e nt M A R s in the c
hart we re Janu ary 2014. W e obtaine d the s u bs e qu e nt M A R s and
re viewe d the m . T he patient d id not pic
k u pone ofhis m e d ic
ations in Fe bru ary.
s blood pre s s u re has not be e n ad d re s s e d ad e qu ate ly. O rd e ringblood pre s s u re
c
he c
ks is not u s e fu lifthe provide rd oe s n
t re view and re s pond to the m .
Patient #3
T his is a46-ye ar-old m an withhype rte ns ion, hype rlipid e m ia, d iabe te s and H IV infe c
tion. H e has
be e n s e e n tim e ly in c
ard iacc
linicfor hype rte ns ion and hype rlipid e m ia. H is blood pre s s u re has
be e n e le vate d at e ve ry c
linic
ale nc
ou nte r so far this ye ar, bu t no m e d ic
ation c
hange s have be e n
m ad e . A t the 1/7/14d iabe te s c
linic
, his blood pre s s u re was 150/90bu t not c
om m e nte d u pon by the
P A . A t the 1/28H IV te le m e d ic
ine visit, his blood pre s s u re was 140/84bu t again not m e ntione d .
A t the 3/12c
hronicc
are c
linicvisit, his blood pre s s u re was 144/90and 130/94, ye t his hype rte ns ion
was rate d as good c
ontroland no m e d ic
ation c
s blood pre s s u re has not be e n ad d re s s e d ad e qu ate ly.
Patient #4
T his is a67-ye ar-old m an withd iabe te s , hype rte ns ion, hype rlipid e m iaand atrialfibrillation for
whic
hhe is antic
oagu late d . T he latte rd iagnos is is not on the proble m list.
O n 7/26/13, he was s e e n in hype rte ns ion c
linicwith a blood pre s s u re of 108/62 and his
hyd roc
hlorothiaz id e was inc
re as e d from 12.5to 25m g/d .
s blood pre s s u re m e d ic
ation s hou ld not have be e n inc
re as e d give n his
re lative ly low blood pre s s u re . It appe ars that this m ay have be e n an e rror, as the d oc
tor d id not
ind ic
ate that s he inte nd e d to inc
re as e the d os e .
Patient #5
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 11
T his is a41-ye ar-old m an withhype rte ns ion, hype rlipid e m ia, as thm aand apros the tiche art valve .
O n 10/10/13, he was s e e n in as thm ac
linic
. H is blood pre s s u re was 158/84bu t not ad d re s s e d .
O n 11/4, he was s e e n in hype rte ns ion c
linic
. H is blood pre s s u re was 142/90, bu t no m e d ic
ation
c
T he re we re no fu rthe r c
hronicc
are note s in the c
hart. H ype rlipid e m iawas not ad d re s s e d at any
c
hronicc
are c
linic
. H is e le c
trolyte and lipid pane ls have not be e n c
he c
ke d in ove raye ar.
s hype rte ns ion and hype rlipid e m iahave not be e n ad e qu ate ly ad d re s s e d . H e
is ove rd u e forac
hronicc
are visit and blood work.
Patient #6
T his is a51-ye ar-old m an with hype rte ns ion, s e izu re s and he patitis C infe c
tion who arrive d at
IR C C on 3/8/13. H is blood pre s s u re has be e n e le vate d forthe m ajority ofhis tim e at IR C C . B lood
pre s s u re c
he c
ks we re ord e re d on s e ve raloc
c
as ions bu t it d oe s not appe ar that the re s u lts we re
re viewe d by aprovid e roru s e d form e d ic
ald e c
ision m aking.
R e view ofthe M A R s d e m ons trate s that he d id not pic
k u p his blood pre s s u re m e d ic
ation from
D ec
e m be r2013to M arc
h2014.
Opinion:T he re is no e vid e nc
e that the blood pre s s u re c
he c
ks are re viewe d by the provide roru s e d
for c
linic
al d e c
ision m aking. E vide ntly the provid e r is not re viewingthe M A R s to e valu ate
m e d ic
ation c
om plianc
e.
Patient #7
T his is a38-ye ar-old m an with hype rte ns ion, hype rlipid e m iaand H IV infe c
tion who arrive d at
IR C C on 9/12/12. O n 3/19, 7/17, and 11/6/13, he was s e e n in c
hronicc
are c
linicforhype rte ns ion
and hype rlipid e m ia. H e was u nd e rgood c
ontrol, withlabs d rawn tim e ly priorto the visit. H owe ve r,
re view of M A R s s hows s u bs tantiallaps e s in m e d ic
ation c
ontinu ity s inc
e his las t c
linicvisit in
N ove m be r2013.
Opinion:T his patient s hou ld be s e e n in c
hronicc
are c
linicand his m e d ic
ation c
om plianc
ec
larified .
Patient #8
T his is a55-ye ar-old m an who arrive d 1/15/13 withahistory ofhype rte ns ion and s e izu re s . H is
bas e line c
linicwas 1/24/13.
O n 3/11, he c
om plaine d that he c
ou ld not s wallow his blood pre s s u re pill, s o the phys ic
ian s witc
he d
him to te razos in, s tartingat 2 m g/d and tape ringu pto 10 m g. T his was his only blood pre s s u re
m e d ic
ation.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 12

linicwithablood pre s s u re of132/84. T his was rate d as
good c
ontrol, bu t hyd roc
hlorothiaz id e was ad d e d . B lood pre s s u re c
he c
ks we re obtaine d ;50% of
the re ad ings we re above goal. O n 5/14, he was s e e n forfollow-u pand ate nololwas ad d e d .
O n 8/15, he was s e e n in s e izu re c
linic
. H is blood pre s s u re was 150/96bu t was not ad d re s s e d .
linic
. H is blood pre s s u re was 150/90and he re porte d that
he had not take n his te raz os in in ove rthre e we e ks . T he m e d ic
ation was d isc
ontinu e d and the othe r
two we re c
ontinu e d u nc
hange d . B lood pre s s u re m onitoringwas ord e re d as we llas afollow u pin
thre e we e ks . T wo ofs ix re ad ings we re high, withthe las t re ad ingbe ing210/40, whic
hprom pte d
the nu rs e to notify the d oc
tor, who ord e re d as tat d os e ofc
lonid ine . T he re pe at blood pre s s u re afte r
c
lonid ine was 160/90and he was s e nt bac
k to the u nit.
O n 12/2, his blood pre s s u re was 180/110. O n re pe at it was 142/88and the patient c
om plaine d of
c
he s t pain. T he nu rs e followe d the c
he s t pain protoc
oland d isc
ove re d that he
s had two d ays
worthofc
he s t tightne s s , e s pe c
ially whe n he lies d own. T he pain was re lieve d by s ittingu p. She
d id not notify aprovide rd e s pite the fac
t that the protoc
ols tate s that the provid e rs hou ld be notified
forallc
as e s .
T he ne xt d ay he was s e e n in s e izu re c
linic
. A t this visit, his blood pre s s u re was 160/104and he
was ad m itte d to the infirm ary afte rbe inggive n as tat d os e ofc
lonid ine . Lisinoprilwas ad d e d . H e
was d isc
harge d the ne xt d ay.
Opinion:T his patient s hou ld have be e n re fe rre d to aprovide rforhis c
om plaints ofc
he s t pain. T he
approac
hto this patient
sc
are has be e n lac
kingin c
ontinu ity. T e raz os in is not re c
om m e nd e d as a
firs t line blood pre s s u re m e d ic
ation.
Diabetes
T he m os t re c
e nt aggre gate d ataat the tim e ofou rvisit re fle c
te d that 55% ofpatients s e e n within
the las t fisc
alye ar we re we llc
ontrolle d (A 1c< 7% ), and 12% we re u nd e r poor c
ontrol(A 1c>
9% ). W e re viewe d five re c
ord s ofpatients e nrolle d in the d iabe te s c
linicand fou nd opportu nities
forim prove m e nt in the two c
as e s d e s c
ribe d be low.
Patient #9
ontrolle d type 2 d iabe te s , hype rte ns ion, hype rlipid e m ia
and hypothyroid ism . H is c
are ove r the pas t ye ar has be e n c
om plic
ate d by nonc
om plianc
e with
m e d ic
ations . H e was s e e n in d iabe te s c
linicon 5/7/13, at whic
htim e his A 1cwas 9.2% (goal<
7% ). It was note d that he had stoppe d takingone ofhis d iabe te s m e d ic
ations in D e c
e m be r. (Fu rthe r
re view re ve ale d that he had ac
tu ally re porte d this to the s am e provid e re ight m onths e arlier.)T he re
was no e xploration into why the patient s toppe d his m e d ic
ation.
O n 7/25, he was s e e n by the nu rs e for pre s s ing c
he s t pain forthe las t 24 hou rs , whic
hs tarte d
withac
tivity and was d e s c
ribe d as c
ons tant and m od e rate in s e ve rity. H e was d e s c
ribe d as c
lam m y,
grim ac
ingand whe e z ing. T he E C G s howe d ne w c
hange s in the ante rior le ad s . T he c
om pu te r
s
inte rpre tation was c
annot ru le ou t ante riorinfarc
t, age u nd e te rm ine d .T he d oc
torwas c
ontac
te d
and gave ord e rs to give him ad os e ofM aalox and s e nd him bac
k to his u nit.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 13
T he phys ic
ian s aw him in follow u p ofthis e ve nt late rthat afte rnoon and note d no m ore c
he s t
pain re lieve d by M aalox...GE R D ? She ord e red no fu rthe r work u p. She had re c
e ntly (7/17)
s igne d labs s howinginad e qu ate ly c
ontrolle d lipid s (c
hole s te rol227, LD L 162), bu t d id not ord er
tre atm e nt orafollow-u pappointm e nt.
H e was s e e n ne xt in d iabe te s c
linicon 9/11. H is A 1cwas wors e at 9.5%. H e was d e s c
ribe d as
ge ne rally nonc
om pliant,whic
hwas not e xplore d fu rthe r. N o m e d ic
ation c
linicby the P A . H is A 1cwas s om e what be tter at 8.4%.
C hole s te rol m e d ic
ation was ad d e d . T he re we re no fu rthe r c
hronicc
are note s ;the patient was
sc
he d u le d to be s e e n on 5/12/14.
T he m os t re c
e nt M A R in the c
hart was Janu ary
s . W he n we re qu e s te d the m ore re c
e nt one s , only
A pril
s c
ou ld be fou nd . It ind ic
ate d that the patient was c
om pliant with ins u lin line m os t ofthe
tim e and was pic
kingu phis oralm e d ic
ations .
sc
ard iovas c
u larrisk is qu ite high;c
om plaints ofc
he s t pain s hou ld the re fore
be pre s u m e d c
ard iacu ntil prove n othe rwise . A lthou gh the patient is re pe ate d ly d e s c
ribe d as
nonc
om pliant, the M A R s d o not s e e m to re fle c
t this. T he statu s ofhis m e d ic
ation c
om plianc
e and
his c
ard iacs ym ptom s s hou ld be e xplore d fu rthe r.
Patient #10
T his is a58-ye ar-old m an withtype 2d iabe te s , hype rte ns ion, hype rlipid e m iaand c
oronary arte ry
d ise as e withhistory ofC A B G x 3who arrive d at IR C C on 10/28/11.
linic
. H is A 1cwas 9.7% and his m e d ic
ations we re inc
re as e d .
A re pe at A 1cwas ord e re d for8/26/13withfollow u pin d iabe te s c
linicon 9/9.
O n 9/9, his A 1cwas no be tte r. T he P A ac
knowle d ge d his poor d iabe te s c
ontrol, ye t m ad e no
c
hange s to the re gim e n. A follow-u pvisit was ord ere d for1/8/14withlabs on 12/19/13.
O n 1/8/14, his A 1cwas 8.8% and his m e d ic
ation was inc
re as e d . Follow-u p was ord ere d for 5/6
withlabs on 4/23. T he re we re no labs forthat d ate file d in the he althre c
ord as ofou rvisit on 5/5.
H e d id have an A 1con 3/28, whic
hwas u nc
hange d .
M A R s d e m ons trate that he has be e n c
om pliant withins u lin.
Opinion: T his patient has m ad e ve ry little progre s s in the pas t ye ar with re gard to his d iabe te s
c
ontrol. P e rhaps he s hou ld be s e e n m ore fre qu e ntly.
General Medicine
W e re viewe d the antic
oagu lation d ataas one of the s u rrogate ind ic
ators for this c
linic
. M os t
patients on C ou m ad in s pe nt the m ajority of tim e within the the rape u ticrange ove r the las t 3-4
m onths . W e s e le c
te d thre e c
harts at rand om to re view. In none ofthe re c
ord s d id the provide rs
qu e ry the patients re gard ingble e d ingc
om plic
ations ;in two ofthe re c
ord s the re was no s u bje c
tive
inform ation at allat one orm ore c
linicvisits . C linic
s oc
c
u rre d tim e ly in two ofthre e
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 14
c
as e s ;howe ve r, in one ofthe two tim e lyc
as e s , the re as on forantic
oagu lation (atrialfibrillation)
was ne ve rm e ntione d at any ofthe c
linicvisits . In fac
t, the patient
s he art was d e s c
ribe d as R R R
(re gu larrate and rhythm )at e ve ry c
linic
ale nc
ou nte r.
HIV Infection/AIDS
W e re viewe d fou r re c
ord s (27%)ofpatients e nrolle d in the H IV c
linic
. T he patients we re s e e n
tim e ly by the ID te le m e d ic
ine phys ic
ian in thre e of fou r c
as e s , and in ge ne rallabs we re d rawn
tim e ly priorto the s e visits . A s is the c
as e in allthe othe rfac
ilities we visite d , ons ite provide rs are
c
om ple te ly u ninvolve d in m onitoringpatients H IV d ise as e . A ntire trovirals are d ire c
tly obs e rve d
the rapy at IR C C , the oretic
ally allowingfor re liable m onitoringof m e d ic
ation c
om plianc
e . If
M A R s we re file d tim e ly into the re c
ord s , this m ight be m ore like ly to oc
c
u r.
Patient #11
T his is a25-ye ar-old m an who was ne wly d iagnos e d withH IV infe c
tion u pon his intake to ID O C
in D e c
e m be r2013. H e was s e e n by ID te le m e d ic
ine on 1/7/14. A s his viralload was u nd e te c
table
and his C D 4c
ou nt was norm al, tre atm e nt was not re c
om m e nd e d . H e was trans fe rre d to IR C C on
1/29and has not be e n s e e n by aprovid e rs inc
e his arrival.
Opinion:T his patient s hou ld be s e e n pe riod ic
ally by the fac
ility phys ic
ian c
ons id e ring his
d iagnos is.
Patient #12
T his is a46-ye ar-old m an withhype rte ns ion, hype rlipid e m ia, d iabe te s and H IV infe c
tion. H e has
be e n s e e n tim e ly in H IV te le m e d ic
ine with labs d one tim e ly prior. H is H IV d ise as e is we ll
c
ontrolle d . R e view of M A R s re ve als blanks for five c
ons e c
u tive d os e s of two of his H IV
m e d ic
ations in Janu ary. T he Fe bru ary and M arc
hM A R s we re not in the c
hart.
Opinion:T he re s hou ld be no blanks on the M A R . Is im pos s ible to te llif the re was m e d ic
ation
d isc
ontinu ity. M A R s ne e d to be file d in the c
hart tim e ly s o provide rs c
an re view m e d ic
ation
c
om plianc
e.
Patient #13
tion, whic
his not liste d on his proble m list. H e had be e n
known to be H IV + d u ringapriorinc
arc
e ration in 2012. H e was re le as e d in D e c
e m be r2012and
was re inc
arc
e rate d in M arc
h2013. A t intake , his H IV infe c
tion was not re c
ognize d and he re fu s e d
H IV te stingbothat N R C and u pon trans fe rto IR C C in M ay 2013. T he re was no e vide nc
e in the
c
hart that anyone at IR C C re alize d he was H IV +, ye t the c
hronicc
are nu rs e ord e re d H IV labs on
7/19/13 and the patient s aw the ID te le m e d ic
ine phys ic
ian on 7/31. A s are s u lt ofthis visit, his
m e d ic
ations we re re s u m e d and as ix we e k follow-u p was ord e re d bu t d id not oc
c
u r for thre e
m onths . T he re afte rhe was s e e n tim e ly withlabs priorto the visits .
Opinion:D e s pite havingaknown d iagnos is ofH IV infe c
tion, this patient
s s tatu s we nt appare ntly
u nre c
ognize d forthe firs t fou rm onths ofhis inc
arc
e ration. W e le arne d that this d e lay was like ly
d u e to the fac
t that the re is no m e c
hanism in plac
e to au tom atic
ally re qu e s t old re c
ord s ofpatients
who are re inc
arc
e rate d ;only thos e who are parole violators are au tom atic
ally re qu e s te d .
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 15
Liver
T he nu rs e as s igne d to he patitis C c
linicis e xtre m e ly knowle d ge able and we llorganize d . T he re
we re two patients ju s t finishingtre atm e nt at the tim e ofou rvisit. T he c
linics e e m e d to be ru nning
we ll. N o iss u e s we re note d .
Pulmonary Clinic
W e re viewe d the aggre gate d ataforFY 2012, 2013and 2014to d ate. Inte re stingly, the re we re 0
patients rate d as poorc
ontrolove rthe las t 21/2 ye ars . W e find this d atasom e what d u biou s , as it is
not in ke e pingwiths im ilars tatistic
s in othe rc
orrec
tionals ys te m s orin the c
om m u nity at large . It
is like ly that at le as t part ofthe proble m is the way the tre atm e nt gu ide line s are writte n. T he s e
gu ide line s s pe ak only to as thm a, ye t alarge portion ofpatients e nrolle d in the c
linicac
tu ally have
C O P D , whic
his as e parate and d istinc
t d ise as e , the tre atm e nt ofwhic
hd iffe rs in im portant ways
from the tre atm e nt ofas thm a.
T he gu id e line appe ars to be bas e d partly on the N ationalH e art, Lu ng, and B lood Ins titu te (N H LB I)
E xpe rt P ane l R e port 3 (E P R 3). For e xam ple , the s e c
tion on as s e s s ings ym ptom s e ve rity is
c
ons iste nt withthe N H LB I re c
om m e nd ations , bu t the as s e s s m e nt ofc
ontrolis not. Fore xam ple ,
the ID O C gu ide line allows patients who u s e u pto afu llc
aniste rofthe irre s c
u e inhale r m onthly
(whic
have rage s 1-2d os e s pe rd ay)to be d e e m e d u nd e rgood c
ontrol, while the N H LB I gu ide line s
rate good c
ontrolas no m ore than twic
e we e kly. T he N H LB I gu ide line s als o take into ac
c
ou nt
ad d itionald ata, s u c
has s ym ptom inte rfe re nc
e withnorm alac
tivity and pe ak flow m onitoringwhe n
as s e s s ingd e gre e of c
ontrol. W e re c
om m e nd that the d e partm e nt ad opt this s trate gy. W e als o
re c
ontrolte rm inology ofwe ll,not we ll,and
ve ry poorlyc
ontrol, in ord e rto he ighte n aware ne s s of
the ne e d to m od ify the rapy forallc
ate gories that are le s s than we llc
ontrolle d .
B os we llP harm ac
e u tic
als , loc
ou nte r
m e d ic
ations for the fac
e ns e d as a W hole s ale D ru g D istribu tor/P harm acy
h m e ans ne w pre s c
riptions faxe d to the
pharm ac
y by 1:00p.m . willarrive at the fac
riptions faxe d by 10
a.m . willbe re c
e ive d the ne xt d ay. E ithe rthe loc
alW algre e ns s tore orthe loc
alhos pitalis the bac
ku ppharm ac
y forobtainingm e d ic
ation whic
k.
P atient s pe c
ificpre s c
riptions , s toc
k pre s c
riptions and c
ontrolle d m e d ic
ations arrive pac
kage d in a
30-d ay bu bble pac
k. O ve r-the -c
ou nterm e d ic
. T he
m e d ic
ation pre paration/storage are ais s taffe d withone fu ll-tim e pharm ac
y te c
hnic
ian, and B os we ll
provide s ac
ons u ltingpharm ac
ist to c
om e on-s ite onc
ription ac
tivity, to
as s e s s pharm ac
y te c
hnic
ian pe rform anc
e and te c
hniqu e and to d e stroy ou td ated orno longe rne e d e d
c
ontrolle d m e d ic
ations pu rs u ant to the re qu ire m e nts ofthe Fe d e ralD ru gA d m inistration (FD A )and
D ru gE nforc
e m e nt A ge nc
tion ofthe m e d ic
ation pre paration/storage are are ve ale d
alarge , c
le an, we ll-lighte d and we ll-m aintaine d are a. A n inte rview withthe pharm ac
y te c
hnic
ian
re ve ale d a knowle d ge able ind ivid u al with s e ve ral ye ars working as a pharm ac
y te c
hnic
ian.
Ins pe c
ate d tight ac
c
ou ntingofc
ontrolle d m e d ic
ations , bothstoc
k and retu rn
ite m s , ne e d le s /syringe s , s harps /ins tru m e nts and
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 16
m e d ic
ou nts ind ic
ate d allwe re c
orre c
t.
A c
om ple te inve ntory is c
ond u c
te d and ve rified we e kly. A d d itionally ins pe c
tion ofthe pe rpetu al
inve ntories and c
ou nts in the infirm ary m e d ic
ation room ve rified all we re c
orre c
t. T he s e
inve ntories are ve rified e ac
hs hift by on-c
om ingand off-goinginfirm ary nu rs ings taff.
A ll pre s c
riptions , c
ontrolle d m e d ic
re c
y te c
hnic
ian. O nc
e re c
e ive d and c
hof
e d in bac
k s toc
k are
s tore d within loc
ke d c
abine ts orthe vau lt, bothofwhic
hare ins id e the loc
ke d and re s tric
te d ac
c
ess
pharm ac
y s torage room . T he pe rpetu alinve ntories forallite m s loc
ate d in the loc
ke d c
abine ts are
c
ou nte d and ve rified e ac
hs hift by on-c
om ingand off-goingnu rs ings taff. T he vau lt inve ntories
are ve rified we e kly by the D ire c
tor of N u rs ingand the pharm ac
y te c
hnic
ian. T he c
ras h c
art
inve ntory is ve rified we e kly or any tim e the plas tics e c
u rity s e al is broke n. T he c
ontrolle d
m e d ic
ation bac
k s toc
k pe rpetu al inve ntory is ve rified ad aily. T he pe rpe tu al inve ntories for
c
ontrolle d m e d ic
ation in front orworkings toc
kis ve rified e ac
hs hift by an onc
om ingand offgoingnu rs ings taffm e m be r.
A c
c
pharm ac
y te c
hnic
ian. T he pharm ac
y te c
hnic
ian and nu rs ingad m inistration are re qu ire d to d raw
ke ys to the irare aat the be ginningofe ac
hs hift and re tu rn the ke ys whe n le avingat the e nd ofthe ir
s hift. In the e ve nt the y wou ld le ave ins titu tionalgrou nd s withthe ir ke ys , the y are c
ontac
te d by
fac
ility arm ory pe rs onne lto im m e d iate ly re tu rn to the ins titu tion. N u rs ings taffpas s the irke y rings
to one anothe r be twe e n s hifts . K e ys to the m e d ic
ation s torage room and loc
ke d c
abine ts are
re s tric
te d to nu rs ingad m inistration, nu rs ings taffand the pharm ac
y te c
hnic
ian. K e ys to the bac
k
s toc
te d to the D ire c
tor of N u rs ingand pharm ac
y te c
hnic
ian. R e frige rator
te m pe ratu re s are m onitore d and d oc
u m e nte d d aily.
D os e-by-d os e m e d ic
e ns e d nu rs ings taff. Inm ate s are m ove d to the he alth
c
are u nit in m e d ic
ation line s two tim e s ad ay to re c
e ive the irm e d ic
ation. N u rs ings taffad m iniste rs
d ire c
ificbliste r pac
k and im m e d iate ly d oc
u m e nts the ad m inistration or
re fu s al on the patient s pe c
ificm e d ic
ord (M A R ). P atients re fu s ing
m e d ic
ation are re qu ire d to s ign are fu s alform at the tim e of re fu s al. M e d ic
ation is d e live re d to
inm ate s in the s e gre gation u nit and ad m iniste re d d os e-by-d os e at c
e lls ide . N u rs ings taffobtains
one d os e of m e d ic
ation from the patient s pe c
ificbliste r pac
k and plac
e s it in a pill e nve lope
appropriate ly labe le d withthe patient
s nam e and nu m be r, the nam e ofthe m e d ic
ation, stre ngth,
d os age and tim e to be ad m iniste re d . T he nu rs e c
arries the e nve lope s to the s e gre gation u nit and is
esc
orte d by s e c
u rity s taffc
e llto c
e ll. A t e ac
hc
e ll, the s e c
u rity s taffm e m be rope ns the solid c
e ll
d oorfood tray s lot. T he inm ate is re qu ire d to c
om e to the c
e lld oor, s how his ide ntific
ation c
ard ,
s tate his nam e and have s om e thingto d rink. T he nu rs e pos itive ly id e ntifies the inm ate , give s him
the m e d ic
ation throu ghthe food tray s lot, obs e rve s inge s tion and perform s am ou th ins pe c
tion.
W he n c
om ple te d , the nu rs e retu rns to the he althc
are u nit and d oc
u m e nts ad m inistration orre fu s al
ofthe m e d ic
ation on e ac
hpatient s pe c
ificM A R .
Laboratory
Laboratory s e rvic
c
e s m e d ic
alc
ontrac
torprovide s 0.75FT E s phle botom y pos itions to d raw
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 17
and pre pare the s am ple s fortrans port to U IC . T he ind ivid u alis ons ite M ond ay throu ghFrid ay for
approxim ate ly s ix hou rs e ac
h d ay. R e s u lts are e le c
tronic
k to the fac
ility,
ge ne rally within 24hou rs vias e c
u re fax line loc
ald e partm e nt. U IC re ports both
to the fac
ility and the Illinois D e partm e nt ofP u blicH e althallre portable c
u rre nt
C linic
alLaboratory Im prove m e nt A m e nd m e nt (C LIA )waive rc
e rtific
ate that e xpire s Janu ary 27,
2015, on file . T he re we re no re ports ofany proble m s withthis s e rvic
e.

W e re viewe d fou rre c
ord s ofwhic
htwo c
ontaine d proble m s .
Patient #1
T his is a31-ye ar-old withahistory ofalc
oholabu s e , ane m iaand u lc
e rative c
olitis. O n 3/24/14, he
pre s e nte d as kingforhis m e d ic
ation u s e d to tre at u lc
e rative c
olitis. H e re c
e ive d iton 3/25;howe ve r,
he had ru n ou t ofthe m e d ic
ine on 2/10whic
hs hou ld not have oc
c
u rre d . H e e nd e d u pbe ings e nt
ou t afe w d ays late rwhe n he pre s e nte d withas ore throat and was fou nd to have atons illarabs c
ess.
H is te m pe ratu re was 101.3and his pu ls e rate was 120. H e was give n an inje c
tion ofantibiotic
and was als o give n s te roids to re d u c
e the s we lling. H e was s e nt bac
k to the ins titu tion on both
antibiotic
s and s te roid s . U pon re tu rn, he was plac
e d in the infirm ary and re le as e d the following
d ay.
Patient #2
T his is a41-ye ar-old who arrive d in the s ys te m on 7/7/11. A t that tim e , he was fou nd to have aright
u ppe r e xtre m ity ne u ropathy s e c
ond ary to a gu ns hot wou nd . O n 3/14/14, he was s e nt to the
e m e rge nc
y room afte rc
om plainingofc
he s t pain at the m id-c
he s t whic
hs tarte d while he was at re st.
H e als o fe lt apre s s u re alongwithhe ad ac
he and d izz ine s s . N othinghad be e n able to re lieve the pain.
A t that tim e , his vitals igns we re norm aland his e le c
troc
ard iogram s howe d nons pe c
ificST and T
wave abnorm alities as we llas aprolonge d Q T phas e and an ac
c
e le rate d ju nc
tionalrhythm . H e was
give n as pirin and nitroglyc
e rin and s e nt to the e m e rge nc
y room . T he re is no e m e rge nc
y room re port
in the c
hart. H e retu rne d laterthat d ay and at the tim e ofretu rn had norm alvitals igns and he was
plac
e d in the infirm ary for24-hou robs e rvation. H e was s e e n by the phys ic
ian the ne xt d ay in the
m orningand d isc
harge d to the hou s ingu nit on nitroglyc
e rin. H e was als o re fe rre d forastre s s te st.
T he stre s s te st that was ord ere d was not approve d throu ghthe c
olle gialre view proc
e s s. O n 3/30, he
again c
om plaine d ofc
he s t pain. H e was plac
e d in the infirm ary and the n re le as e d to the hou s ing
u nit. H e had not be e n s e e n ye t in ac
hronicc
are c
linic
.

ord s ofpatients s e nt ou t fore ithe r c
ons u ltations orproc
e d u re s . O fthos e 10,
five c
ontaine d proble m s , m os tly re late d to tim e ly follow u p.
Patient #1
T his is a 63-ye ar-old who arrive d in the s ys te m 1/28/13 with GE R D , hype rlipid e m ia and
hype rte ns ion. H e had firs t re porte d blood in his s tools in Ju ne 2013. W e c
ou ld not find anu rs e
sc
re e n on intake and his re c
ord from the H illC orre c
tionalC e nte r,whe re he had be e n in Ju ne 2013,
appare ntly is not loc
atable . O n 3/23/14, he was re fe rre d to c
olore c
tals u rge ry. A
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 18
c
olonos c
opy re ve ale d apos te riorre c
talm as s and aC T ofthe c
he s t, abd om e n and pe lvis we re als o
ord ere d . O n the C T s c
an, no nod e s we re fou nd . A n u ltras ou nd ofthe re c
tu m has be e n ord e re d and
willbe pe rform e d ne xt we e k. It appe ars that this patient m ay have atu m or, the d iagnos is ofwhich
m ay have be e n d e laye d .
Patient #2
T his patient is a 57-ye ar-old with pe pticu lc
e r d ise as e , c
olitis, C rohn
s d ise as e , ane m ia and
GE R D . H e was s e nt ou t on 2/13/14forac
olonos c
opy. T he re port ind ic
ate s large ps e u d o polyps
withou t c
olitis. H e has be e n m aintaine d on R e m ic
ad e by the gas troe nte rology s pe c
ialist. A lthou gh
he has be e n re c
e ivingR e m ic
ad e , m os t re c
e ntly on 4/21, the re is no d oc
ord .
Patient #3
T his is a 25-ye ar-old who arrive d 2/2/13. H e has be e n d iagnos e d with te s tic
u lar c
anc
e r with
m e tas tas is to the pu lm onary valve . H e has had ale ft orc
hiec
tom y and he als o had s u rge ry to re m ove
the m e tas tas is to the pu lm onary valve . H e als o have ad e c
u bitu s ove rhis c
oc
c
yx. H e has be e n told
that no m ore c
he m othe rapy c
an be provid e d . T his patient s hou ld be ac
and id ate form e d ic
alparole .
Patient #4
T his is a33-ye ar-old who had no c
hronicproble m s who was s e nt ou t on 3/20/14forabiops y of
hype rplas tictiss u e on his lowe rlip. T he biops y re port s u gge s ts apapillom aofthe lowe r lip and
this was e xc
ise d on 3/20. H owe ve r, the re has be e n no follow u p.
Patient #5
hronicproble m s , s e nt ou t forA c
hille s te nd on re pairon 3/28/14. H is
inju ry oc
c
u rre d on 3/1while he was playingbas ke tball. H e has had his re pairon 3/28, ye t the re is
no s u rgic
ald oc
ord .
Unscheduled Offsite and Onsite Visits

ord s of whic
h fou r we re proble m atic
. T he type s of proble m s we ide ntified
inc
lu d e d lac
k of tim e ly c
ontinu ity of c
are , lac
k of tim e ly ons ite visits and lac
k of appropriate
re fe rrals .
Patient #1
T his is a41-ye ar-old who had no c
hronicproble m s who pre s e nte d on 3/14/14c
om plainingofc
he s t
pain. A t that tim e , his vitals igns we re norm aland an E K G was d one whic
hs howe d as low he art
rate. T he phys ic
ian was c
alle d and he ord ere d as pirin and nitroglyc
e rin and the n s e nt the patient to
the hos pital. W he n the patient retu rne d , the phys ic
ian ord e re d that he be plac
e d in the infirm ary to
be s e e n by the phys ic
ian the ne xt d ay. H e was s e e n by the phys ician and at that tim e was
as ym ptom atic
, and s o he was d isc
harge d to the hou s ing u nit. H is e m e rge nc
y room re port
re c
om m e nd e d as tre s s te s t as s oon as pos s ible . O n 3/30, he again pre s e nte d withc
he s t pain and
was plac
e d in the infirm ary. T he s tre s s te st was d e nied by the c
olle gialre view proc
e s s and the y
ind ic
ate d ins te ad he s hou ld be m onitore d ons ite . The re was no re fe rralforthe c
hronicc
are c
linic
d e s pite his s low he art rate and re pe ate d c
he s t pain.
Patient #2
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 20
19
T his is a35-ye ar-old withs c

olios is and e c
z e m a. O n 3/18/14, he pre s e nte d withs ym ptom s ofhis
he art rac
ing, his pu ls e was 105and he pe rc
e ive d the fe e lingofhe art s pas m s . A n E K G was d one
and it s howe d as inu s arrhythm ia. T he phys ic
ian ord e re d him to re tu rn to the hou s ingu nit bu t the re
has be e n no follow-u pand he has not be e n s e e n s inc
e.
Patient #3
T his is a 38-ye ar-old with no c
hronicproble m s . O n 2/5/14, he c
om plaine d of c
he s t pain
e xac
e rbate d by bre athingd e e ply. H is vitals igns we re norm alas was his e le c
troc
ard iogram . T he
phys ic
ian was c
ontac
te d and he ord e re d apain m e d ic
ine and that the patient be plac
e d in the
infirm ary forobs e rvation. T he pain was re lieve d by the pain m e d ic
ine and he was re le as e d to his
hou s ingu nit to be followe d u pin one we e k. T he follow u pby the phys ic
ian ne ve roc
c
u rre d .
Patient #4
T his is a48-ye ar-old with hype rte ns ion and type 2 d iabe te s as we llas as e izu re d isord e r and a
history ofalc
oholabu s e . O n 2/7/14, he pre s e nte d withd izz ine s s . A t that tim e he was re c
e iving
m e tform in, lisinopril and D ilantin. H is orthostaticblood pre s s u re s d id not d e m ons trate a
s ignific
ant c
hange . H is finge rs tic
k was 160. A t his bas e line c
hronicc
are visit, his he m oglobin A 1c
was 8.1and this was as s e s s e d as good c
ontrol. H e s hou ld be followe d u pm ore c
are fu lly and the
d e finition ofgood c
ontrolford iabe te s s hou ld be re viewe d withthe provid e rs .
Infirmary Care
onfigu re d as thre e , fou r-be d room s and thre e s ingle be d room s .
T wo ofthe s ingle be d room s are fu nc
tioningne gative airpre s s u re re s piratory isolation room s . T he
u nit is m inim ally s taffe d with at le as t one re giste re d nu rs e 24 hou rs ad ay, s e ve n d ays awe e k
whe ne ve rthe infirm ary is oc
c
u pied . Se c
u rity s taffthat is as s igne d to the he althc
are u nit pe rform s
rou tine rou nd s throu ghthe infirm ary.
Inm ate porte rs pe rform allthe janitoriald u ties in the infirm ary. It was le arne d the porte rs have had
no trainingin the prope r s anitizingof infirm ary room s , be d s , fu rnitu re , line ns , infe c
tiou s and
c
om m u nic
able d ise as e s , blood -borne pathoge ns , bod ily flu id c
le an-u p or m e d ic
al inform ation
c
onfid e ntiality.
A n infirm ary d aily re port is m aintaine d whic
h lists the nam e and nu m be r ofe ac
hpatient in the
infirm ary, s tatu s , fore xam ple ac
u te , c
hronic
,c
risis watc
h, e tc
., d iagnos is, d iet, labte s ts , ad m iss ion
d ate and tim e , d isc
harge d ate and tim e and c
om m e nts .
A n infirm ary d aily ac
tivity re port is als o m aintaine d whic
hd e tails the nam e , nu m be r, d iagnos is,
loc
ation and d ate s ad m itte d and d isc
harge d from ou ts id e hos pitals , patients goingou ts ide the
fac
ility forou tpatient s e rvic
es, c
om m u nity hos pitale m e rge nc
y room oc
c
u rre nc
e s , on-s ite s pe c
ialty
c
linic
s and any d e aths .
O n the d ay ofthe infirm ary ins pe c
tion, A pril18, 2014, the re we re nine patients in the infirm ary;
thre e m e ntalhe althpatients and s ix m e d ic
alpatients . T he s ix m e d ic
alpatients we re ad m itte d with
the followingiss u e s .
1. A 45-ye ar-old ad m itte d A pril4, 2014, withe s ophage als tric

tu re s and c
olon re s e c
tion d u e
to c
anc
e rofthe c
olon.
2. A 25-ye ar-old ad m itte d Fe bru ary 27, 2014, withpostope rative le ft ne phre c
tom y;e xc
ision
ofabd om inalm as s involvingthe aortaand infe riorve nac
avave s s e ls ;te s tic
u larc
anc
e rwith
m e tas tas is to the he art.
3. A 39-ye ar-old ad m itte d A pril16, 2014, with ac
u te m ye loblas ticle u ke m ia;d e ge ne rative
c
hange s ofthe T -s pine ;right pu lm onary m as s e s withple u rale ffu s ion.
4. A 29-ye ar-old ad m itte d A pril13, 2014, with le ft lowe r qu ad rant pain and d ys u ria;r/o
kid ne y s tone .
5. A 26-ye ar-old ad m itte d A pril17, 2014, withr/o panc
re atitis.
6. A 23-ye ar-old ad m itte d A pril16, 2014, withright u ppe rqu ad rant pain forfive d ays .
A ll s ix re c
ord s c
ontaine d phys ician and nu rs ingad m iss ion d oc
u m e ntation. A ll patients we re
c
las s ified as c
hronicor ac
u te , and d oc
u m e ntation was provid e d m ore fre qu e ntly than re qu ire d .
A lld oc
u m e ntation was in the SO A P form at as re qu ire d by the D e partm e nt ofC orre c
tions O ffic
e
ofH e althSe rvic
ord e d as ord e re d by the
phys ician for the ac
u te c
y for the c
hronicc
are
patients . M e d ic
ations we re d oc
u m e nte d on e ac
h patient s pe c
ificm e d ic
ation ad m inistration
re c
ord .
ord s and fou nd thre e c
as e s in whic
hthe c
are was ve ry proble m atic
. T he s e
are d e s c
ribe d be low. O fthe re m ainingfive c
as e s , fou rwe re s e e n tim e ly.
Patient #1
T his is a37-ye ar-old re c
e ntly d iagnos e d type 2 d iabe ticwho was ad m itte d to ID O C on 1/30/14
and trans fe rre d to IR C C on 2/19/14. T he d ay afte rhis arrival, ac
od e 3was c
alle d to his u nit fora
trans ient e pisod e ofs lu rre d s pe e c
h, d izz ine s s and inability to walk. T he d oc
torwas notified and
the patient was plac
e d in the infirm ary for obs e rvation. H e had as im ilar bu t m ild e r e pisod e the
followingd ay.
O n 2/22, anothe r d oc
tor s aw the patient and wrote ave ry le ngthy note d etailings ym ptom s of
nu m bne s s involvingthe right s id e ofthe bod y as we llas the fac
e , alongwiths lu rre d s pe e c
hand
e xpre s s ive aphas ia;s ym ptom s highly c
om patible withane u rologice ve nt in the te rritory ofthe le ft
m id d le c
e re bral arte ry. Y e t the phys ic
ian e xplaine d to patient that his s ym ptom s d o not
c
orre s pond to any anatom ic
ald e fe c
t.H e ord e re d no fu rthe rwork-u pforthe patient, bu t ke pt him
in the infirm ary forc
ontinu e d obs e rvation.
O n 2/24(aM ond ay)at 4:40p.m ., the patient had anothere pisod e . T he R N c
alle d the d oc
tor, who
ord ere d herto te st the patient
s re fle xe s and try walkingthe patient, the n c
allhim bac
k. It took two
people to walk the patient, whos e gait was d e s c
ribe d as s hu ffling, and who le ane d he avily on the
nu rs e whe n liftingthe right le g. H is right le gstre ngthwas d e sc
ribe d as we ak, and he had abs e nt
re fle xe s at the right kne e and ankle and no plantarres pons e onthe right. T he le ft-s ide d re fle xe s we re
norm al. T he d oc
torwas notified ofthe se find ings bu t ord e re d no fu rtherwork u p.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 21
B y the ne xt d ay, the right grip s tre ngth was s till d e s c

ribe d as notably we ake r and right le g
s lightly laggingd u ringgait. O n 2/26, the re was s tills light we akne s s in the right grip, bu t his gait
was bac
k to norm al.
T he re we re no provide rnote s be twe e n the d ate ofad m iss ion (2/22)and 3/3, whe n he was s e e n by
the P A and d isc
harge d from the infirm ary.
O n 3/18, the patient was s e e n in d iabe te s c
linicby the P A . T he re is no m e ntion ofthe ne u rologic
e ve nt.
s s ym ptom s are highly s u gge s tive ofan ac
u te c
e ntralne rvou s s ys te m e ve nt
su c
has astroke , whic
his am e d ic
ale m e rge nc
y and s hou ld have be e n tre ate d as s u c
h. It was not
appropriate to ad m it apos s ible s troke patient to the infirm ary;he s hou ld have be e n s e nt to the
hos pitalfor fu rthe r e valu ation and tre atm e nt. H e re qu ire s ad d itionalwork u p for his ne u rologic
e ve nts .
Patient #2
T his is a39-ye ar-old m an who firs t pre s e nte d withs ym ptom s ofbac
k pain and le ft le gwe akne s s
on 12/18/13. H e was s e e n by the d oc
tor that d ay. T he e xam c
ons iste d e ntire ly of patient in
whe e lc
hair bu t able to walk s lowly. N o bac
k te nd e rne s s . D T R in lowe r e xtre m ities brisk and
s ym m e tric
al. SLR ne gative .H e ad m itte d the patient to the infirm ary for24hou rs, s aw the patient
the ne xt d ay, noted walks s lowly withc
ane and d isc
harge d him from the infirm ary.
O n 12/23, the patient fe llin the bathroom . H e reported no pain bu t was d e s c
ribe d as u nable to be ar
we ight and ne e d ingas s istanc
e to m ove . H e was plac
e d bac
k in the infirm ary. O ve r the ne xt fe w
d ays , he re porte d that he was u nable to wiggle his toe s and was bare ly m ovinghis le gs and fe e t. H e
was s e e n by aphys ic
ian on 12/24 and 12/30. B othe xam s appe ar to be in s tark c
ontrast to what
nu rs ing s taff c
ons iste ntly d e s c
ribe as appare ntly profou nd lowe r e xtre m ity we akne s s , ofte n
d oc
u m e ntingthat he re qu ire s from one to thre e staffm e m be rs to as s ist him withtrans fe rring, and
that nu rs ings taffm u s t re pos ition his le gs in be d as he is u nable to m ove the m . D e s pite the s e d etaile d
nu rs ingnote s, the phys ic
ian d oc
u m e nte d fu llle gstre ngthin his note d ate d 12/30;no othe rm u s c
le
grou ps were te ste d . H e ord ere d awalke rand to e nc
ou rage am bu lation.
T he patient as ke d m u ltiple tim e s to be s e nt to the hos pitalforfu rthe re valu ation.
O n 1/2/14, the d oc
torfinally d id am ore thorou ghne u rologice xam and note d that the patient c
ou ld
raise his le gs bu t was not able to m ove his toe s or ankle s . H e had d e c
re as e d ankle re fle xe s and
hype rac
tive kne e re fle xe s , and had d e c
re as e d s e ns ation to light tou c
hand pinpric
k u pto his m id
c
he s t. H e d e c
ide d the patient had as pinalc
ord le s ionand ord e re d an M R I.
T he d oc
tors aw the patient again the ne xt d ay and note d that he is bare ly able to m ove toe s .H is
as s e s s m e nt was u ppe r m otor ne u ron le s ion, and the plan was to c
hange to c
hronicinfirm ary
s tatu s and await approvalforthe M R I.
M e anwhile , the patient was now re qu iring3-4s taffas s istanc
e fortrans fe rs and be d m obility.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 22
T he d oc
tors aw him again on 1/6, again ac
knowle d ge d his paralys is and planne d to await approval
forM R I. Finally, that e ve ningthe R N re qu e s te d that the patient be s e nt to the E D afte rs he had to
lowe rhim to the floord u ringatrans fe rand note d that he c
ou ld not m ove orfe e lhis le gs.
A t the hos pitalhe was fou nd to have A M L (ac
u te m ye loge nou s le u ke m ia)/m ye loid s arc
om awith
ac
u te c
ord c
om pre s s ion and s taye d in the hos pitalforove rthre e m onths . H e re tu rne d aparaple gic
.
Opinion:A c
u te m otor we akne s s ofthe le gs s hou ld raise im m e d iate c
onc
e rn for an ac
u te s pinal
c
ord inju ry. T he s e riou s ne s s ofhis c
ond ition appe are d to be m ore e vid e nt to nu rs ings taffthan it
was to the d oc
tor. E ve n afte rthe d oc
torfinally e xam ine d the patient appropriate ly and c
orre c
tly
c
onc
lu d e d that he had as pinalc
ord le s ion, he faile d to appre c
iate the u rge nc
y ofhis c
ond ition.
T hat one wou ld s im ply ord e ran M R I in the fac
e ofrapid ly progre s s ive paralys is is ine xplic
able .
T his patient s hou ld have be e n s e nt e m e rge ntly to the hos pital rathe r than langu ishingin the
infirm ary fortwo we e ks . H ad the appropriate e valu ation and tre atm e nt be e n provide d tim e ly, he
m ay not have s u ffe re d s u c
hs e ve re d e fic
its .
Patient #3
T his is a 31-ye ar-old m an who was ad m itte d ac
u te ly to the infirm ary on 4/22 afte r be ing
hos pitalize d foras ku llfrac
tu re withintrac
ranialble e d ingc
au s inginc
re as e d intrac
ranialpre s s u re .
T he re is an ad m iss ion note d ate d 4/19/14whic
his m arke d late e ntry.T he re is no phys ic
ale xam ;
ins te ad the provide rwrote not s e e n at ad m iss ion.It is not s igne d .
T he re is aprogre s s note on the s am e d ate withthe s am e hand writing. T he phys ic
ale xam c
ontains
ne arly no inform ation, only A & O and wou nd on s c
alphe aling.T he re is no ne u rologice xam .
T he ne xt provide rnote is d ate d awe e k late r, whe n the patient was s e e n by anothe rphys ic
ian. H e
was s e e n twic
e m ore that we e k (4/29and 4/30), withthe s e c
ond note large ly ind e c
iphe rable . T he re
we re no fu rthe rprovide rnote s as ofthe d ate ofou rvisit (5/5).
Opinion: T his patient has not be e n ad e qu ate ly e xam ine d give n the natu re ofhis inju ries . H e has
not be e n s e e n tim e ly by the provid e rs while ad m itte d to the infirm ary.
Infection Control
T he D ire c
torofN u rs ing(D O N )fu nc
tions as the fac
ility infe c
tion c
ontrolnu rs e . W he n re qu ire d ,
s he inte rfac
e s withthe C ou nty D e partm e nt ofP u blicH e althand the Illinois D e partm e nt ofP u blic
H e alth (ID P H ). T he D O N m onitors , c
om ple te s and s u bm its to ID P H allre portable c
as e s . Skin
infe c
u ltu re d and tre ate d . P e rthe D O N , the re is alow
oc
c
u rre nc
e of c
u ltu re -prove n m e thic
illin re s istant Staphyloc
oc
c
u s au re u s (M R SA ) infe c
tions .
H e althC are U nit nu rs ings taffc
ond u c
ts m onthly s afe ty and s anitation ins pe c
tions in the d ietary
d e partm e nt and pe rform s pre -as s ignm e nt food hand le r e xam inations for staff and inm ate s to
work in the d ietary d e partm e nt. A tou r ofthe he althc
are u nit, inc
lu d ingthe infirm ary, ve rified
pe rs onalprote c
tive e qu ipm e nt (P P E)available to staffin allare as as ne e d e d .
A d d itionally, P P E is inc
y re s pons e bags. P u nc
tu re proofc
ontaine rs forthe
d ispos alofs yringe s /ne e d le s and othe rs harpobje c
are u nit
as ne e d e d . T he fac
ility u s e s a national c
om m e rc
ial was te d ispos al c
om pany for d ispos ingof
MM ay
ay2014
2014
IIl
ll
i
noi
i
noi
ss Ri
Ri
verC
verC or
orrrec
ect
t
i
onal
i
onalCC ent
ent
er
er
PP age
age 24
23
m e d ic
alwas te . Ins titu tionals taffis traine d in c
om m u nic
able d ise as e s and blood -borne pathoge ns
annu ally.
T he H e althC are U nit is c
le an withthe janitoriald u ties pe rform e d by inm ate porters who have had
no trainingin the propers anitation ofinfirm ary room s , be d s , fu rnitu re and line ns , c
om m u nic
able
d ise as e s , bod ily flu id c
le an-u p or blood -borne pathoge ns . H e alth C are U nit porters lau nd e r the
infirm ary line ns in ahe alth c
are u nit lau nd ry room . A te st of the was hingm ac
hine hot wate r
te m pe ratu re ind ic
ate d ate m pe ratu re ofonly 125d e gre e s F. T his te m pe ratu re is too low to as s u re
the prope rc
le aningand s anitizingofpote ntially bod y flu id s oile d be d line n.
A d d itionally, it was re porte d the hot water te m pe ratu re in the ins titu tionallau nd ry is rou tine ly
m e as u re d at 125d e gre e s F, whic
hagain is too low. In ord e rto prope rly s anitize , line ns are to be
e xpos e d to water at le as t 160 d e gre e s Ffor 25 m inu te s or give n able ac
h bathhavingan initial
s tartingc
onc
e ntration of100parts pe r m illion and ate m pe ratu re ofat le as t 140d e gre e s Fforat
le as t 10m inu te s .
T he im pe rviou s vinyl-c
oatingon e xam ination s tools and table s and infirm ary m attre s s e s was note d
to be torn or c
rac
ke d , whic
h pre ve nts proper s anitizing and allows for pote ntial c
ros s c
ontam ination be twe e n patients . T he ite m s in qu e s tion s hou ld e ithe rbe re u phols te re d orre plac
ed .
Su c
hite m s s hou ld be ins pe c
te d m onthly as apart ofthe s afe ty and s anitation proc
ess.
Inmates Interviews
Six ins u lin d e pe nd e nt inm ate s we re inte rviewe d . A ll s ix had be e n d iagnos e d s e ve ral ye ars
pre viou s ly, and alls ix we re knowle d ge able re gard ingthe irc
hronicd ise as e . Fou rofthe s ix we re
anc
e ofthe ir he m oglobin A 1cblood le ve l. Fou r ofthe s ix
e nt he m oglobin A 1cblood le ve l. A lls ix re porte d be inge valu ate d
by the phys ic
ian e ve ry 3-4 m onths and havingthe ability to pe rform blood glu c
os e m onitoring
priorto the ad m inistration ofins u lin. A lls ix re porte d the pre viou s M e d ic
alD ire c
tord id not inform
the m ofthe ir he m oglobin A 1cle ve ld u ringd iabe ticc
linic
. T he inm ate s s tate d the y e ithe r had to
s pe c
ific
ally as k for the re s u lts or nu rs ings taff wou ld s hare the A 1cre s u lts d u ringthe nu rs ing
portion ofthe c
linic
. In re s pons e to qu e stioning, alls ix s tate d that, in ge ne ral, s e c
u rity s taffwas
aware the y we re ins u lin d e pe nd e nt d iabe tic
s bu t we re not s e ns itive to the m e d ic
al iss u e s
s u rrou nd ingthat iss u e . A llwe re ofthe opinion the pre viou s M e d ic
alD ire c
tor, who was re s pons ible
forthe ird iabe ticc
are , d id not d o agood job.
a.m . and 11:30a.m . and d inne ris s e rve d be twe e n 4:00p.m . and 5:30p.m . A lls ix inm ate s s tate d
bre akfas t is always c
old c
e re aland bre ad . It was re porte d that m orningins u lin is ad m iniste re d
be twe e n 4:00a.m . and 5:00a.m ., and afte rnoon ins u lin be twe e n 3:15p.m . to 3:45p.m .
A lls ix inm ate s agre e d on the followingiss u e s .
1.
2.
3.
4.
Lac
k ofad e qu ate e xe rc
ise tim e
B ottom bu nk ord e rs are not au tom atic
ally provide d to ins u lin d e pe nd e nt d iabe ticpatients
N o pod iatry c
are
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 25
e ive ins u lin priorto e atingand s om e tim e s afte re ating
6. W he n e valu ate d by an off-s ite s pe c
u lty ge ttingbac
ialist
ialist
7. Se c
u rity s taffnot always followingphys ic
ian ord ers , i.e . d u rings hake d owns , takings hoe s
that had be e n ord ere d by the phys ic
ian
8. E ve n thou ghhard c
and y is approve d fors ale in the inm ate c
om m iss ary, whe n inm ate s c
arry
c
and y to s e lf-tre at low blood s u gar, s e c
u rity s taff will take the c
and y whe n rand om
s hake d owns are be ingc
ond u c
te d
9. T he pre viou s M e d ic
alD ire c
tord id not m anage the ird ise as e we ll.
Dental Program
Executive Summary
O n A pril16-18and M ay 5, 2014, ac
om pre he ns ive re view ofthe d e ntalprogram at Illinois R ive r
C C was c
om ple te d . Five are as of the program we re ad d re s s e d inc
lu d ing:1)inm ate s ac
c
e s s to
tim e ly d e ntalc
are ;2) the qu ality of c
are ;3) the qu ality and qu antity of the provide rs ;4) the
ad e qu ac
y ofthe phys ic
alfac
are ;and 5)the ove ralld e ntal
program m anage m e nt. T he followingobs e rvations and find ings are provide d .
T he c
linicits e lfc
ons ists ofthre e c
hairs and u nits in thre e line arc
linicbays in alongc
linicare a.
T he s pac
e is ad e qu ate in s ize . T he c
hairs and u nits are old and s howingwe ar, fad ingand s om e
c
orros ion. T he intra-oralx-ray u nit is in as e parate room and is old and in only fairc
ond ition. T he
c
abine try is old and s howingwe arand c
orros ion. T he re is an ad joiningroom hou s ingthe d e ntal
laboratory and s te rilization are a. T he re is als o an ad joiningoffic
e for staff. Ins tru m e ntation and
e qu ipm e nt are ad e qu ate to m e e t the ne e d s ofthis ins titu tion.
C om pre he ns ive c
are d e live ry was an are aofc
onc
e rn. A lthou ghan e xam ination and c
hartingof
the te ethwas pe rform e d prior to rou tine c
are , and atre atm e nt plan d e ve lope d , the e xam ination
its e lf was inc
om ple te and inad e qu ate . N o d oc
u m e nte d e xam ination of the s oft tiss u e s nor
pe riod ontal as s e s s m e nt was part of the e xam ination and tre atm e nt proc
e s s . H ygiene c
are and
prophylaxis was not provide d prior to re s torations . R e s torations proc
e e d e d withou t appropriate
intra-oralrad iographs . O ralhygiene ins tru c
tions we re s e ld om provide d .
onc
e e d from a
d oc
u m e nte d and ac
c
u rate d iagnos is. N on-re s torable was ofte n provide d as ad iagnos is. T his is
not ad iagnos is, pe rs e . C u rre nt and ad e qu ate x-rays we re not always pre s e nt to proc
e e d withd e ntal
e xtrac
tions .
ons tru c
e ofc
are d e live ry inc
lu d e d in
the c
om pre he ns ive c
are proc
e s s . A re c
ord re view re ve ale d that partiald e ntu re s proc
e e d e d withou t
an ad e qu ate c
om pre he ns ive e xam ination and tre atm e nt plan. A pe riod ontale xam and
as s e s s m e nt was not d oc
u m e nte d . B e c
au s e , as m e ntione d , the c
om pre he ns ive e xam ination and
tre atm e nt plans are inc
om ple te ly d e ve lope d , it was im pos s ible to as c
e rtain if allne c
e s s ary c
are
was c
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 26
Inm ate s ac
c
e s s s ic
kc
allthrou ghad aily s ic
kc
alls ign-u p. Inm ate s withu rge nt c
om plaints (pain
and s we lling)are e nc
ou rage d to u s e d e ntals ic
kc
all. T he inm ate s are s e e n that m orningforatriage d
e valu ation. U rge nt c
are ne e d s are ad d re s s e d at that tim e . O the rs are re s c
he d u le d bas e d on le ve lof
ne e d . R ou tine c
are was not provide d at s ic
kc
all. T he s ys te m works s u c
c
e s s fu lly and inm ate s with
u rge nt c
are ne e d s are s e e n in atim e ly m anne r. T he SO A P form at was we lld oc
u m e nte d .
Inm ate s c
an re qu e s t rou tine c
are viathe inm ate re qu e s t form . T he s e inm ate s are s e e n and e valu ate d
e ve ry Frid ay ofthat we e k. T he y are s c
he d u le d ac
c
ord ingly. T he y c
ontinu e to be re s c
he d u le d u ntil
tre atm e nt is c
om ple te d .
T he he althhistory s e c
ord is not thorou ghand poorly d e ve lope d . T he re is no
s ys te m in plac
e to re d flagpatients withm e d ic
alc
ond itions that re qu ire m e d ic
alc
ons u ltation or
inte rve ntion priorto d e ntaltre atm e nt.
as ke d , the c
linic
ian ind ic
ate d that he d oe s not rou tine ly take blood pre s s u re s on the s e patients .
T he s te rilization are ais s m alland s hare d withthe d e ntallaboratory. P roper s te rilization flow is
inte rru pte d by laboratory e qu ipm e nt.
Safe ty glas s e s we re not worn by patients d u ringtre atm e nt. N o rad iation haz ard s igns we re pos te d
in the are awhe re x-rays are take n.
T he c
ontinu ing qu ality im prove m e nt program is inad e qu ate and poorly u tilize d . T he d e ntal
program is not involve d in any ongoingC Q I s tu d ies at this tim e . It s hou ld d e ve lop s tu d ies and
c
orre c
tive ac
tions to ad d re s s the we akne s s e s d e s c
ribe d in the bod y ofthis re view.

Illinois R ive r C C has ad e ntals taff of one fu ll-tim e d e ntist, one fu ll-tim e as s istant, two P R N
as s istants and afu ll-tim e hygienist. T his is m inim als taffingforan ins titu tion ofthis s ize . H owe ve r,
the d e ntalte am works we lltogethe r and s e e m s to m ake it work we ll. A lls taffare e m ploye d by
W e xford H e althSys te m s .
Recommendations: N one . Staffings e e m s ad e qu ate .

T he c
linicc
ons ists ofthre e c
hairs and u nits in thre e line ar c
linicbays in alongc
linicare a. T he
c
hairs and u nits are old and s howingwe ar, fad ingand s om e c
orros ion. A llofthe ope ratories are
fu nc
tioningad e qu ate ly at this tim e . T he re is no panore x in this c
linic
. T he x-ray u nit for
pe riapic
aland bite wingx-rays is in as e parate room and rathe rold and in only fairc
ond ition. I was
told it s tillworks s atisfac
torily. T he d e ve lope ris old bu t working. T he au toc
lave is rathe rne w and
fu nc
tions we ll. T he c
om pre s s or is old e r bu t works we ll. T he ins tru m e ntation is ad e qu ate in
qu antity and qu ality. T he hand piec
e s are old e rbu t we llm aintaine d and re paire d whe n ne c
e s s ary.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 27
T he c
abine try is rathe r old and s howingwe ar and c
tionally O K . T his d oe s
m ake d isinfe c
tion ofc
abine t s u rfac
e s and work areas m ore d iffic
u lt.
T he c
linicits e lfc
arou nd e ac
hu nit is ac
c
e ptable . P rovid e rand as s istant have ad e qu ate room to work and none ofthe
c
hairs inte rfe re withe ac
hothe r. T he re was as e parate ste rilization and laboratory room ofad e qu ate
s ize . It had as m allbu t ad e qu ate work s u rfac
c
om m od ate prope rinfe c
tion
c
orne rofthe room . T he s taffhad
as e parate room foroffic
e s pac
e . It was ad e qu ate in s ize and was the s pac
e in whic
had m inistrative
d u ties we re pe rform e d . T he fac
ility and e qu ipm e nt are ad e qu ate to m e e t the ne e d s of this
ins titu tion.
Recommendations:
1. T he c
tion to m e e t the ne e d s ofthe inm ate popu lation at
Illinois R ive rC C .
2. R e plac
e m e nt ofthe u nits s hou ld be c
ons id e re d s om e tim e in the ne arfu tu re .

O bs e rvation of s anitation and s te rilization proc
e d u re s re ve ale d that s u rfac
e d isinfe c
tion was
ad e qu ate and ac
c
om plishe d with appropriate anti-m ic
robial wipe s . A ll ins tru m e nts , inc
lu d ing
hand piec
e s , we re prope rly bagge d and s te rilize d . P rote c
tive c
ove r barriers we re u s e d whe ne ve r
pos s ible .
T he s te rilization are ais s m alland s hare d withthe d e ntallaboratory. P roper s te rilization flow is
inte rru pte d be c
au s e of this s haringof s pac
e . Flow s hou ld go from d irty to c
le an to ste rilize to
s torage withno c
ros sove rorinte rfe re nc
e . Laboratory e qu ipm e nt inte rfe re d withthis flow.
O bs e rvation at c
hair s ide d u ringc
are d e live ry re ve ale d that patients d id not we ar prote c
tive
e ye we ar.
O bs e rvation in the x-ray are are ve ale d that no rad iation warnings igns we re in plac
e to warn of
pote ntialrad iation haz ard s .
Recommendations:
1. R e -arrange the s te rilization/labare as o that the prope rs te rilization flow is ac
c
om plishe d .
3. A warnings ign be pos te d in the x-ray are ato warn ofrad iation haz ard s .

I looke d back two ye ars and fou nd the s te riliz ation logs to be in place. T he y s howe d that
au toc
lavingwas ac
c
u m e nte d . T he c
linicm aintains awe e kly logto
ind ic
ate that the te sts we re s e nt. N o ne gative re s u lts we re obtaine d .
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 28
Comprehensive Care
W e re view 10d e ntalre c
tive tre atm e nt c
las s ified as C ate gory 3patients . O ne
ofthe m os t bas icand e s s e ntials tand ard s ofc
are in d e ntistry is that allc
om pre he ns ive (rou tine )c
are
proc
e e d from athorou gh, we lld oc
u m e nte d intraand e xtra-orale xam ination and awe lld e ve lope d
tre atm e nt plan, to inc
lu d e allne c
e s s ary d iagnos ticx-rays . A re view of10inm ate re c
ord s re ve ale d
that althou ghad oc
u m e nte d e xam ination ofthe tee thwas perform e d priorto rou tine c
are , and a
tre atm e nt plan d e ve lope d and followe d , the e xam ination its e lfwas inc
om ple te and inad e qu ate. N o
s oft tiss u e s e xam ination orperiod ontalas s e s s m e nt was part ofthe e xam inationortre atm e nt proc
e s s.
H ygiene c
are and prophylaxis was provide d in none ofthe 10patient re c
ord s re viewe d . R e storations
proc
e e d e d withou t appropriate intra-oralrad iographs , to inc
lu d e bite wingand /orperiapic
alx-rays ;
c
are was provide d from the inform ation from the panore x rad iograph. T his rad iograph is not
d iagnos ticforc
aries . P e riod ontalas s e s s m e nt and tre atm e nt was not provide d in any ofthe re c
ord s .
Fu rthe r, oralhygiene ins tru c
ord as part ofthe
tre atm e nt proc
ess.
Recommendations:
u m e nte d
tre atm e nt plan.
lu d e ape riod ontalas s e s s m e nt and d e taile d e xam ination ofallhard and
s oft tiss u e s .
3. In allc
aries .
4. H ygiene and pe riod ontalc
ess.
5. T hat c
e s and d e ntal
prophylaxis.
u m e nte d .
Dental Screening
A lthou ghIllinois R ive rC C is not are c
e ption and c
las s ific
ation c
ord s to
ins u re the re c
e ption and c
las s ific
ation polic
tive 04.03.102,
sec
om plianc
e.
Extractions
u m e nte d
and ac
c
u rate d iagnos is. M any e ntries provid e d u nre s torable as a d iagnos is. T his is not a
d iagnos is, pe r s e . A d iagnos is is bas e d on histologic
al as s u m ptions d e rive d from s ym ptom s ,
e xam ination and c
linic
al te s ts . H owe ve r, non-re s torable c
ou ld be c
ons id e re d a re as on for
e xtrac
tion rathe rthan othe rac
c
e ptable tre atm e nts .
In thre e ofthe te n re c
ord s re viewe d , ad e qu ate and c
u rre nt x-rays we re not available .
Recommendations:
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 29
1. Ins u re that allrad iographs u s e d to provide orals u rge ry proc

e d u re s be c
u rre nt and inc
lu d e
allne c
e s s ary inform ation.
2. P rovid e and ac
c
u rate and appropriate d iagnos is as re as on fore xtrac
tion.
s s hou ld proc
ord e d on
ad d re s s e d firs t. T he d e ntalprogram at Illinois R ive rC C ins u re d that allinm ate s re c
e ivingpartial
d e ntu re s we re provide d hygiene s e rvic
e s , to inc
lu d e s c
aling, d e bride m e nt and oral hygiene
ins tru c
tions . H owe ve r, ape riod ontale xam and as s e s s m e nt was not d oc
u m e nte d in any of the
re c
ord s . B e c
au s e the c
om pre he ns ive e xam ination and tre atm e nt plans are inad e qu ate ly and
inc
om ple te ly d e ve lope d and d oc
u m e nte d , it is alm ost im pos s ible to as c
e rtain ifallne c
e s s ary c
are ,
inc
lu d ingope rative and /ororals u rge ry tre atm e nt, is c
ation ofre m ovable
partiald e ntu re s .
Recommendations:
1. T hat a thorou gh c
om pre he ns ive e xam ination and a we ll d e ve lope d and d oc
u m e nte d
tre atm e nt plan, inc
lu d ing bite wing and /or pe riapic
al rad iographs and pe riod ontal
as s e s s m e nt, proc
e e d allc
are , inc
s.
e s s and that the
c
Dental Sick Call

W e re viewe d d e ntals ic
kc
allproc
e d u re s to d ete rm ine ifthe y are ad e qu ate .
Inm ate s ac
c
e s s s ic
kc
kc
alls ign-u p. T he y are s e e n that m orningforatriage d
e valu ation. U rge nt c
are ne e d s are ad d re s s e d at that tim e . O the rs are re s c
he d u le d bas e d on le ve l
ofne e d . O nly u rge nt c
are ne e d s are ad d re s s e d at s ic
kc
all. R ou tine c
are is not provid e d on s ic
k
c
all. T he SO A P form at was u s e d in allc
as e s re viewe d and the inm ate c
om plaint was ad d re s s e d .
Se ve ralre c
ord s ind ic
ate d u nre s torable as the e ntry in the (A )s e c
tion ofthe SO A P note . T his is
not s tric
tly ad iagnos is, e s pe c
ially forc
om plaints ofpain.
Recommendations:
1. P rovid e we lld e ve lope d , m e aningfu ld iagnos isin the (A )s e c
tion ofthe SO A P note e ntry.
Treatment Provision
Inm ate s who s u bm it inm ate re qu e s t form s are s e e n e ve ry Frid ay fortriage and e valu ation and at
that tim e provide d an appointm e nt to ad d re s s the ir tre atm e nt ne e d s . T he s c
he d u le be c
om e s the
waitinglist and allinm ate s s c
he d u le d are s e e n within thre e to five we e ks .
Sic
kc
allis ru n as an ope n s ign u pand is available e ve ry m orning. T re atm e nt d e c
isions are m ad e
at that tim e . T re atm e nt is provid e d im m e d iate ly ifne c
e s s ary and allothe rs are give n appointm e nts
bas e d on prioritize d ne e d s as d e te rm ine d by the d e ntist. T his is agood s ys te m and ins u re s that
u rge nt c
are ne e d s are ad d re s s e d in atim e ly m anne r;in this c
as e , that s am e d ay. Inm ate s re qu e s t
rou tine c
are viathe inm ate re qu e s t form and alls u c
hinm ate s are s e e n and e valu ate d e ve ry Frid ay
ofthat we e k. T he y are the n give n an appointm e nt, bas e d on this e valu ation, to provid e ne c
e s s ary
tre atm e nt. R ou tine c
are patients c
ontinu e to be re s c
he d u le d u ntilthe irc
are is c
om ple te . T he wait
tim e be twe e n appointm e nts is approxim ate ly s ix we e ks . T he re is no waitinglist, pe rs e .
Recommendations: N one . T he s ys te m is fairand e qu itable and re s pond s ve ry we llto inm ate c
are
ne e d s . U rge nt c
are is s e e n the s am e d ay. A ve ry s atisfac
tory ne e d s ge ne rate d s ys te m ofc
are is in
plac
e.
Inm ate s c
an s ign u p d aily for d e ntals ic
kc
alland be s e e n that d ay. T his als o applies to m e d ic
al
s ic
kc
all. A re view ofthe Illinois R ive rC C inm ate he althc
are u nit proc
e d u re s bookle t re ve als that
itd oe s not inc
lu d e the d aily s ic
kc
alls ign-u pproc
e d u re foru rge nt d e ntalc
are as itd oe s form e d ic
al.
Recommendations:
1. Inc
lu d e the d e ntals ic
kc
alls ign u p proc
e d u re s , alongwith m e d ic
al, in the Inm ate H e alth
C are U nit P roc
e d u re s B ookle t.

Illinois R ive r C C has an ad e qu ate and rathe r we ll d e ve lope d polic
y and proc
e d u ral m anu al
d oc
u m e nte d in the P roc
e d u ral B u lle tin, H e alth C are P rogram s . It ad d re s s e s all of the are as
c
onc
e rne d , e xc
e pt it m ake s no m e ntion ofthe d aily ope n s ic
kc
alland how to ac
c
e s s u rge nt d e ntal
c
are .
Recommendations:
1. A d d as e c
tion in the P roc
e d u ralB u lle tin, H e althC are P rogram s , ad d re s s ingd aily d e ntals ic
k
c
alland ac
c
e s s ingu rge nt d e ntalc
are .
Failed Appointments
T he faile d appointm e nt rate was abit high, althou ghnot alarm ingly. T he u s u alre asons form iss ing
orre fu s ingan appointm e nt are that the inm ate d oe s not want to pay the $5.00c
o-pay, orgood food
at c
how that d ay, ornic
e d ay to be ou ts ide . Inm ate s are c
alle d d own to s ign are fu s al
form ifthe y failto s how foran appointm e nt. T he d e ntalprogram is m akingan e arne s t atte m pt to
avoid faile d appointm e nts .
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 31
30
Recommendation: N one

T he d e ntal re c
ord is m aintaine d with the m e d ic
al file at Illinois R ive r C C , s o all m e d ic
al
inform ation is available to the d e ntals tafffrom the m e d ic
alre c
ord . T he he althhistory on the d e ntal
c
hart is u pd ate d at the tim e ofwhat is c
alle d an initiale xam inationat this ins titu tion. T his is a
m od ified c
om pre he ns ive e xam ination from whic
h a tre atm e nt plan is d e ve lope d . T his he alth
history is rathe r inad e qu ate and d oe s not d ire c
tly ad d re s s all of the c
om prom ise d m e d ic
al
c
ond itions that m ay affe c
t how d e ntalc
are is provid e d . T he re is no s ys te m in plac
e to re d flag
patients with m e d ic
alc
ond itions that c
an affe c
t d e ntalc
are . A llin all, the he alth history in the
d e ntalc
hart is poorly d e ve lope d and not ve ry thorou gh.
linic
ians ind ic
Recommendations:
alhistory s e c
al
c
ialpre c
atc
ofthe provide r
e s pe c
alproc
e d u re.
Specialists
T he d e ntalprogram at Illinois R ive rC C u tilize s W e s te rn Illinois O raland M axillofac
ialSu rge ry
Ltd . in Gale s bu rg, Illinois forc
as e s re qu irings pe c
ialorals u rge ry e xpe rtise .
P atient [redacted] was s e nt to orals u rgery foran e valu ation ofale s ion. T he re was no write -u p
in the d e ntalre c
ord d e s c
ribingthe le s ion (loc
ation, s ize , d u ration, etc
.)and the re was no d iffe re ntial
d iagnos is provide d in the rec
ord . T he re ason he was s e nt to the orals u rgeon was not ind ic
ate d .
Recommendations:
1. T horou ghly d oc
u m e nt in the d e ntalre c
ord allfind ings and re as ons that le d to are fe rralto
the s pe c
ialist re qu ire d . P rovide allinform ation pe rtine nt to the c
ond ition be ingre fe rre d .
Dental CQI
T he d e ntalprogram
s c
ontribu tion to the C Q I c
om m itte e is m onthly d e ntals tatistic
s . N othingis
d one withthe s e s tatistic
s from the re . T he d e ntalprogram is not involve d in any ongoingqu ality
im prove m e nt stu d ies at this tim e .
Recommendations:
1. E valu ate program d e fic

ienc
ies and ne e d s as ou tline d in this re port throu gh ongoing
c
ontinu ing qu ality im prove m e nt stu d ies that ad d re s s the s e d e fic
ient are as . D e ve lop
c
orre c
tive ac
tions and proc
e d u re s to im prove thos e are as .
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 32
Mortality Review
T he re we re thre e d e aths at IR C C in the pas t ye ar, inc
lu d ingone hanging. W e re viewe d the othe r
two c
as e s and fou nd d istu rbinglaps e s in c
are that ve ry like ly c
ontribu te d to the patients d e aths .
Patient #1
T his was a55-ye ar-old m an withahistory ofhe patitis C , hypothyroid ism and bipolard isord e rwho
was ad m itte d to ID O C throu ghN R C on 10/25/12, trans fe rre d to IR C C on 11/20/12, and d ied of
c
om plic
ations ofm e tas taticlu ngc
anc
e ron 6/14/13. H e had agre ate rthan 40pac
k aye ars m oking
history, and as trongfam ily history oflu ngc
anc
e r, withhis m othe r and two s iste rs d yingofthe
d ise as e . H is c
ou rs e u nfold e d as follows :
O n the d ay afte rhis arrival, 11/21/12, he was s e e n by the R N fors pittingu pblood .T he patient
s howe d the nu rs e aqu arte r-s ize d am ou nt ofblood s ittingon pape rtowe l. T he nu rs e gave the patient
ac
ontaine rand ins tru c
te d him to c
allifthe re was any inc
re as e in he m optys is. H e was not re fe rre d
to aprovide r.
Late r that e ve ning, the s am e nu rs e d oc
u m e nte d that the patient had aqu arte r s ize d am ou nt of
blood y s pu tu m in the s pe c
im e n c
u p. H e ras s e s s m e nt was he m optys is,and the plan was c
ontinu e
to obs e rve .A gain the patient was not re fe rre d to aprovide r.
T he ne xt m orning, anothe rnu rs e d oc
u m e nte d that the patient had no blood y s pu tu m form e ,bu t
d id have s om e visu alc
om plaints . She re fe rre d the patient to the e ye d oc
tor.
O n 11/25, the patient s aw the LP N forad re s s ingc
hange ofhis foot and s howe d the nu rs e tiss u e s
c
ontainingblood y s pu tu m . H e was re fe rre d to M D SC the ne xt d ay.
O n 11/26, the phys ic
ian s aw the patient, who reporte d inte rm itte nt he m optys is and right-s id e d
ple u riticc
he s t pain. She ord e re d ac
he s t x-ray, s pu tu m and blood work. T he c
he s t x-ray was d one
on 11/30, and s howe d , foc
alopac
ity proje c
te d ove rthe right late ralu ppe rlu ngz one . R e c
om m e nd
follow-u p c
he s t C T to e xc
lu d e a lu ngm as s . T he re port was s igne d on 12/3 by the ord e ring
phys ic
ian bu t not ac
te d u pon;no fu rthe rwork-u pwas pu rs u e d .
O n 2/7, the d oc
tors aw the patient in c
hronicc
are c
linic
.H e c
om plaine d ofc
he s t tightne s s in the
u ppe rc
he s t. She ord e re d ac
he s t x-ray in one we e k.
O n 2/14, the c
he s t x-ray was d one and s howe d the inte rvald e ve lopm e nt ofright u pperlobe opac
ity
s e e n e xte nd ingfrom the hilu m to the right lu ngape x, ne w s inc
e prior stu d y...right u ppe r lobe
opac
ity appe ars to be re late d to u pperlobe c
ollaps e withe le vation ofthe right m inorfiss u re . T his
m ay be re late d to aright hilar/su prahilar ne oplas m . Fu rthe r e valu ation with C T of the c
he s t is
re c
om m e nd e d .T he re port was s igne d by the phys ic
ian on 2/19, bu t again not ac
te d u pon.
O n 2/28, the patient pre s e nte d to nu rs e s ic

kc
allre qu e s tinghis x-ray re s u lts . H e was re fe rre d to the
phys ic
ian and s e e n on 3/1 at he patitis C c
hronicc
are c
linic
.H e c
om plaine d of ongoingc
he s t
tightne s s . T he re is no m e ntion ofthe abnorm alc
he s t x-ray that s he pre viou s ly s igne d . H e r plan
was to re pe at the c
he s t x-ray and s e e the patient again whe n the x-ray re s u lts we re bac
k.
O n 3/5, the x-ray was re pe ate d and again s howe d the right u ppe r lobe opac
ity withc
ollaps e and
again aC T was re c
om m e nd e d . T his tim e s he finally d id ac
knowle d ge the abnorm alfind ings whe n
s he s aw the patient on 3/8, and re fe rre d him (non-u rge ntly) for aC T of the c
he s t. T his was
d isc
u s s e d at U M on 3/26, and it was d e c
ide d to m od ify the re qu e s t to aC T gu ide d biops y.
M e anwhile , on 3/23, he pre s e nte d withpain in the right c
ollarbone and was s e e n by an R N , who
c
alle d the d oc
tor. She ord e re d an x-ray on M ond ay 3/25, M otrin and ic
e . T he x-ray s howe d a
pathologicfrac
tu re ofthe right c
lavic
le . T he phys ic
ian s aw the patient that d ay, ord e re d ac
lavic
le
s trapand ad m itte d him to the infirm ary.
O n 4/2, the re is anote s tatingthat IR willnot s c
he d u le him forthe biops y withou t aC T firs t. T his
was approve d and pe rform e d on 4/9. It s howe d a3c
m right u ppe rlobe lu ngm as s oc
c
lu d ingthe
right u ppe r lobe bronc
hu s withe nlarge d m e d ias tinallym phnod e s and alyticle s ion ofthe right
c
lavic
le .
O n 5/8, he u nd e rwe nt biops y ofthe right c
lavic
le whic
hc
onfirm e d m e tas taticnon-s m allc
e lllu ng
c
anc
e r H e was re fe rre d to onc
ology on 5/14, was approve d by U M on 5/28 and the patient was
s e e n on 6/5. T he onc
ologist re c
om m e nd e d rad iation tre atm e nt whic
hthe patient d e c
line d . H e d ied
nine d ays late r.
T he W e xford re view was d one by the tre atingd oc
torwho c
onc
lu d e d that e arly inte rve ntion was
not pos s ible and that the re was no way to im prove patient c
are , ac
onc
lu s ion with whic
h we
s tre nu ou s ly d isagre e .
Opinion:T his patient had c
las s ics igns and s ym ptom s of c
anc
e r from lite rally the m om e nt he
arrive d at IR C C ;the s e we re ac
tive ly ignore d by bothnu rs ings taffand the d oc
torfor m ore than
thre e m onths . H ad work u p be e n initiate d tim e ly, whe n the c
anc
e r was at a s tage that was
re s e c
table , it wou ld like ly have s ignific
antly prolonge d his life . W e inqu ire d afte r this provide r
and we re told that no longe rworks forW e xford . W e wou ld s u gge s t that this c
as e be re porte d to
the m e d ic
alboard .
Patient #2
T his was a40-ye ar-old m an who d ied on 1/23/14ofm e tas taticre c
talc
anc
e r. H e was firs t ad m itte d
to ID O C in 2000. H e firs t be gan c
om plainingofc
ons tipation in Janu ary 2011, at whic
htim e his
we ight was 195pou nd s . H e was not re fe rre d to the d oc
torat that tim e . H e re tu rne d withthe s am e
c
om plaint in M ay 2011 and had los t 10 pou nd s . H e s aw the phys ic
ian for c
ons tipation and
abd om inalpain that was wors e withs itting, and u rinary s ym ptom s . H e d e nied blood in the s tool.
T he d oc
tore xam ine d his abd om e n bu t d id not d o are c
tale xam . She ord e re d an abd om inalx-ray
and labs , whic
hwe re norm al.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 33
O n 12/22/11, he pre s e nte d to the LP N s tatings om e thingis wrongand that he was los ingwe ight.
H e was now d own to 158 pou nd s . H e s aw the d oc
torthat d ay and the d oc
tor d id are c
tale xam ,
fou nd no m as s e s and no blood in the s tool. (O fnote , alld oc
tors who e xam ine d him s u bs e qu e ntly
c
ou ld fe e lam as s in the re c
tu m ). She ord e re d m ore labs and follow u pin one m onth.
B lood was d rawn on 12/30and s howe d m ild iron d e fic
ienc
y ane m ia. T he d oc
tors aw him in Janu ary
and ord e re d stoolc
ard s . T he s e c
am e bac
k pos itive in Fe bru ary, and in M arc
hhe was re fe rre d for
c
olonos c
opy, whic
hwas pe rform e d on 4/13/12and s howe d alarge tu m orin the re c
tu m . P athology
s howe d invas ive ad e noc
arc
inom a.
A lthou gh his c
are proc
e e d in atim e ly and appropriate m anne r from this point on, his d ise as e
c
ontinu e d to progre s s and afte ralongand c
om plic
ate d c
ou rs e , he u ltim ate ly s u c
c
u m be d .
Opinion:Give n his c
ons te llation ofs ym ptom s , c
olonos c
opy s hou ld have be e n obtaine d tim e ly
1
afte rthe ane m iawas id e ntified , rathe rthan 3 /2 m onths late r.

W e re viewe d the m onthly m inu te s whic
hc
ontaine d as u bs tantialam ou nt ofd atawhic
his re porte d
m onthly bas e d on ins titu tionald ire c
tive re qu ire m e nts . H owe ve r, the re is no d oc
u m e ntation in the
m inu te s ofan analys is ofwhat the d atam e ans and whe the rthe s e rvic
e s provid e d are ofad e qu ate
qu ality and if not, how to im prove the qu ality. T he e ntire m inu te s appe ar to be d atac
olle c
tion,
bu t the re is no organize d approac
hto im provingthe qu ality ofs e rvic
e s . W e d isc
u s s e d this with
the le ad e rs hipte am .
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 34
Recommendations
1. Fillthe M e d ic
alD ire c
torand H e althSe rvic
e A d m inistratorpos itions .
2. Fillthe M e d ic
alD ire c
torvac
anc
y A SA P .
3. A ppoint an inte rim H C U A .
4. T he D ire c
tor of N u rs ings hou ld not be ad d itionally fu nc
tioningas the c
ontrac
tor s ite
m anage r.
Intrasystem Transfers:
1. T he qu ality im prove m e nt program s hou ld m onitorwhe the rproble m s are c
orre c
tly
id e ntified and c
ontinu ity ofc
are is fac
ilitate d by this proc
ess.
Medical Records:
1. M A R s m u s t be file d tim e ly into the he althre c
ord s s o that provide rs c
an re fe r to the m to
m onitorpatients m e d ic
ation c
om plianc
e.
2. T he proble m list s hou ld be ke pt at the front ofthe c
hart, on topofothe rpape rwork orin its
own s e c
tion, s o that it c
an be re ad ily ac
c
essed .
3. T he arc
hive d re c
ord s ofallpatients , whe the r re le as e d orparole d , s hou ld be im m e d iate ly
re qu e s te d u pon the irre inc
arc
e ration.
Nursing Sick Call:
1. Sic
kc
allc
ond u c
te d by R e giste re d N u rs e s .
2. Se gre gation s ic
kc
alls hou ld not be c
ond u c
te d throu ghthe s olid s te e lc
e lld oor.
3. C olle c
tc
om ple te vitals igns at e ac
hs ic
kc
alle nc
ou nte r.
1. A llc
hc
hronicc
are c
linicvisit.
2. P atients e nrolle d in the c
hronicc
are program s hou ld be s e e n ac
c
ord ingto the ird e gre e of
d ise as e c
ontrol, rathe rthan the c
ale nd arm onth.
3. W he n nu rs e s note laps e s in m e d ic
ation c
om plianc
e , e ithe rwithK O P ornu rs e d ispe ns e d
m e d ic
ation, this s hou ld be re porte d to the provide rand the patient s hou ld be s c
he d u le d
foran appointm e nt to d isc
u s s ad he re nc
e.
4. W he n aprovide rord e rs blood pre s s u re m onitoring, thos e re ad ings s hou ld be rou te d bac
k
to the ord eringprovid e r.
5. T he re m u s t be c
linic
alove rs ight ofthe qu ality ofc
are provide d , bothloc
ally by aqu alified
M e d ic
alD ire c
tor, and c
e ntrally by W e xford .
1. T he qu ality im prove m e nt program s hou ld m onitorwhe the r, afte ru ns c
s e rvic
e are provide d , the re is tim e ly re c
e ipt ofoffs ite s e rvic
e re ports and follow-u pvisits
withthe prim ary c
are c
linic
ian d u ringwhic
had isc
u s s ion is d oc
u m e nte d re gard ingthe
find ings and plan.
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 35
1. T he qu ality im prove m e nt program s hou ld m onitorthe pre s e nc

e ofoffs ite s e rvic
e re ports
and tim e ly follow-u pvisits withthe prim ary c
are phys ic
ian d u ringwhic
hthe find ings and
plan are d isc
u ssed .
Infection Control:
1. Inm ate porters ne e d to be traine d in c
om m u nic
able and infe c
tiou s d ise as e s , blood -borne
pathoge ns , bod ily flu id c
le an-u p, the prope rs anitizingofinfirm ary room s , be d s , fu rnitu re
and the ne e d form e d ic
alc
onfid e ntiality.
2. Infirm ary be d d ingand line ns m u s t be c
ons ide re d infe c
tiou s and lau nd e re d appropriate ly.
Mortality Reviews:
1. D e aths s hou ld be re viewe d by s om e one othe rthan the tre atingphys ic
ian.
CQI:
c
olle c
tion.
s trate gies .
M ay 2014
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 36

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
Name
Inmate ID
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
M ay 2014
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
Illi
noi
s Ri
verC orrec ti
onalC enter
P age 37
Hill Correctional Center (HCC)

Report
May 7-9, 2014
Prepared b y the Medical Oversight

Commi tt ee R on Shansk y,
MD K aren Sa yl or, MD
Larry Hewitt, RN Karl
Me yer, DDS
Contents
Overview....................................................................................................................................3
Findings .....................................................................................................................................5
C linicSpac
e and Sanitation .....................................................................................................6
N u rs ingSic
k C all.....................................................................................................................7
C hronicD ise as e M anage m e nt..................................................................................................8
P harm ac
y/M e d ic
Laboratory .............................................................................................................................18
U ns c
e s ................................................................................................19
U ns c
he d u le d O ns ite Se rvic
e s ................................................................................................ 19
Sc
e s ................................................................................................... 19
Infirm ary C are .......................................................................................................................21
Infe c
tion C ontrol...................................................................................................................22
D e ntalP rogram ......................................................................................................................24
M ay 2014
H illC orrec ti
onalC enter
P age 2
Overview
O n M ay 7-9, 2014, we visite d the H e nry H illC orrec
tionalIns titu tion (H C C )in Gale s bu rg, Illinois.
T his was ou rfirs t s ite visit to H C C and this re port d e s c
om m e nd ations .
D u ringthis visit, we :
al
als e rvic
e s are a
are s taff
u m e nts
W e thank W ard e n A kpore and his s taff for the ir as s istanc

e and c
oope ration in c
ond u c
tingthe
re view.
Executive Summary
H illC orre c
tionalC e nte r was bu ilt as ne w c
ons tru c
tion and ope ne d in O c
tobe r 1986. Sinc
e that
tim e , the phys ic
alplant has be e n we llm aintaine d .
H illC orre c
tionalC e nte ris am e d iu m -s e c
u rity prison that hou s e s m e d iu m -s e c
u rity m ale offe nd e rs .
T he c
u rre nt popu lation is approxim ate ly 1843inm ate s . T he ave rage le ngthofinc
arc
e ration is two
ye ars . T he ins titu tion is not are c
e ption c
e nte rbu t has an infirm ary and an ou tpatient m e ntalhe alth
m iss ion.
als e rvic
e s are provid e d throu ghac
ontrac
tu alagre e m e nt withthe Illinois
D e partm e nt ofC orre c
tions and W e xford H e althSou rc
e s , loc
ate d in P itts bu rgh, P A . O ve rs ight and
m onitoring of the m e d ic
al program is provid e d by a s tate -e m ploye d H e alth C are U nit
A d m inistrator(H C U A ).
T he m id le ve lprovid e rpos ition was ju s t vac
ate d one m onthago. T he pre viou s nu rs e prac
titione r
got ajobin the c
om m u nity bu t has be e n c
om ingin afe w d ays pe r we e k to he lp ou t while the
M e d ic
alD ire c
toris on athre e -we e k vac
ation.
O fthe fac
ilities ins pe c
te d to d ate , H illC orre c
tionalC e nte r is the be s t s taffe d fac
ility, withonly
one nu rs e prac
titione rvac
anc
y. T he re is as trongm e d ic
ald e partm e nt le ad e rs hipte am c
ons isting
ofthe H C U A , D ire c
torofN u rs ingand M e d ic
alR e c
ord s D ire c
tor. A lthou ghthe M e d ic
alD ire c
tor
pos ition is fille d , he d oe s not appe ar to pe rform s om e ofthe ad m inistrative re s pons ibilities ofa
M e d ic
alD ire c
tor. T he re are als o c
linic
alc
onc
e rns . It was re porte d the re is ve ry little s tafftu rnove r
and abs e nte e ism and , as are s u lt, low u s e ofove rtim e .
M ay 2014
H illC orrec ti
onalC enter
P age 3
T he re c
ord s were in good c
ond ition, with no loos e filingand we ll m aintaine d . H owe ve r, the
proble m list is ke pt bu ried u nd e rthe ord e rs he e ts and is not always u pd ate d .
Log books have be e n d e ve lope d for ge ne ral popu lation u rge nt and non-u rge nt s ic
k c
all,
s e gre gation s ic
kc
all, s e gre gation we llne s s c
he c
ks ,infirm ary ad m iss ions and off-s ite u rge nt c
are ,
as we llas non-u rge nt c
ons u ltations . T his le ve loforganization m ad e it e as y to trac
k and re view
m e d ic
altre atm e nt.
W ithre s pe c
t to the c
hronicc
are program , patients we re s e e n tim e ly ac
c
ord ingto polic
y forthe ir
c
hronicd ise as e c
linic
s ;that is to s ay, the y are s e e n e ve ry fou rm onths re gard le s s ofthe ird e gre e of
d ise as e c
ontrol. W hile this works we llforpatients withs table c
ontrolle d c
ond itions , it e xpos e s the
re s t ofthe patients to the d e le te riou s e ffe c
ts ofs u boptim ald ise as e m anage m e nt forlongpe riod s
of tim e . W e s ay this be c
au s e we ofte n obs e rve d a laiss e faire approac
h to c
hronicd ise as e
m anage m e nt whe re s u boptim ally c
ontrolle d d ise as e was not ad d re s s e d aggre s s ive ly e nou gh, or
s om e tim e s not ad d re s s e d at all. It was appare nt that provide rs we re not obje c
tive ly e valu ating
patients m e d ic
ation c
om plianc
e by re viewingthe M A R s , and the re fore tre atm e nt inte rru ptions
we re goingu nre c
ognize d and u nad d re s s e d .
W ithre s pe c
t to s c
e s , we c
om m only fou nd inad e qu ate oru ntim e ly follow u p.
W e als o fou nd that whe n the plan ofc
are was c
hange d this was not c
onve ye d to the patient.
U ns c
he d u le d ons ite s e rvic
e s re ve ale d poorpe rform anc
e by the nu rs e s in not ad e qu ate ly ad d re s s ing
patients withpos s ible c
he s t pain.
U nlike m any ofthe othe rfac
ilities we have visite d , allc
hronicc
ond itions are ad d re s s e d at e ve ry
c
hronicc
are c
linicvisit. T he c
hronicc
are nu rs e has inve nte d am u lti-c
linic
c
hronicc
are form
forthis pu rpos e . W e fou nd this nu rs e to be highly organize d and e ffic
ient;c
le arly one ofthe be s t
c
hronicc
are nu rs e s we have e nc
ou nte re d .
U nlike the m ajority of fac
ilities pre viou s ly ins pe c
te d , nu rs ings taff at H illC orre c
tionalC e nte r
ad m iniste r m e d ic
ation d ire c
tly from the pharm ac
y pre pare d patient-s pe c
ificbliste r pac
k and
d oc
u m e nt s u c
hat the tim e ofad m inistration on e ac
hpatient-s pe c
ificm e d ic
ation ad m inistration
re c
ord (M A R ).
T he H C U A has d e ve lope d an e xc
e lle nt program , inc
lu d ingawritte n jobd e s c
ription fortraining
he althc
are u nit inm ate porters in infe c
tiou s and c
om m u nic
able d ise as e s , blood -borne pathoge ns ,
bod ily flu id c
le an-u p, infirm ary room s , s howers , be d s and fu rnitu re c
le aning and m e d ic
al
c
onfide ntiality. A d d itionally, inm ate porters are provide d the H e patitis B vac
c
ine s e ries .
W e re viewe d five d e aths of patients who e xpire d s inc
e Janu ary 2013 and fou nd the c
are to be
e xtre m e ly proble m aticin two c
as e s , bothof whic
h involve d avoidable d e lays in d iagnos is and
tre atm e nt, whic
hlike ly c
ontribu te d to the tim ingofthe ird e m ise .
M ay 2014
H illC orrec ti
onalC enter
P age 4
Findings
T he le ad e rs hipte am , withthe e xc
e ption ofthe M e d ic
alD ire c
tor, appe ars to be qu ite c
apable . B oth
the H e althSe rvic
e A d m inistratorand the D ire c
torofN u rs ingd e m ons trate d to u s afirm knowle d ge
ofthe proc
e s s e s and as e ns e ofove rs ight re s pons ibility for thos e proc
e s s e s . O n the othe r hand ,
althou ghthe M e d ic
alD ire c
torwas on vac
ation at the tim e ofou rvisit, we d id he ar from s e ve ral
s taffm e m be rs that at tim e s inte rac
tions withhim we re le s s than ple as ant. It was s u gge s te d to u s ,
as an e xc
u s e for his be havior, that in fac
t he was workingtoo m any jobs . In ad d ition to his
inte rpe rs onal d e fic
ienc
ies , we als o ide ntified s om e c
linic
al c
onc
e rns . O ne nu rs e prac
titione r
ind ic
ate d that d iffic
u lties withthe M e d ic
alD ire c
torle d to he rre c
e nt d e partu re . She c
u rre ntly fills
in on apart-tim e bas is.
P os ition
M e d ic
alD ire c
tor
N u rs e P rac
titione r
D ire c
torofN u rs ing
P s yc
hiatrist
C linic
alP s yc
hologist
M e ntalH e althP rofe s s ional
C linic
alSoc
ialW orke r
Lic
e ns e d P rac
tic
alN u rs e s
H e althInform ation A s s oc
iate
R ad iology T e c
hnic
ian
P harm ac
y Tec
hnic
ian
StaffA s s oc
iate
D e ntist
D e ntalH ygienist
O ptom e try
P hys ic
alT he rapist
P hys ic
Total
C u rre nt FT E
1.0
1.0
1.0
1.0
0.45
1.0
1.0
1.0
8.0
12.0
1.0
4.0
0.4
1.0
1.0
1.0
2.0
Fille d
1.0
0.2
0.05
0.5
38.60
0.2
0.05
0.5
37.60
V ac
ant
1.0
1.0
1.0
0.45
1.0
1.0
1.0
8.0
12.0
1.0
4.0
0.4
1.0
1.0
1.0
2.0
State /C ont.
C ontrac
t
C ontrac
t
State
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
State
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
C ontrac
t
1.0
T he re is as trongle ad e rs hipte am withthe e xc

e ption ofthe fu ll-tim e M e d ic
alD ire c
tor. T he s tre ngth
ofthe te am inc
lu d e s the H e althC are U nit A d m inistrator, D ire c
torofN u rs ingand
M ay 2014
H illC orrec ti
onalC enter
P age 5
M e d ic
alR e c
ord s D ire c
tor. T he re are e ight fu ll-tim e re giste re d nu rs ingpos itions and 12fu ll-tim e
lic
e ns e d prac
tic
alnu rs ingpos itions and allofthe pos itions are fille d . O u t of38.60approve d FT E s ,
the re is only 1.0FT E nu rs e prac
titione rpos ition vac
ant.
A s re porte d by the D ire c
tor ofN u rs ing(D O N )the re is m inim als tafftu rnove r, lim ite d c
all-offs
and u s e ofove rtim e and no re fu s alofove rtim e .
A re view ofm e d ic
als taffc
e ns u re ind ic
ate s taffwhic
hhas be e n appropriate ly
traine d , are c
u rre ntly lic
tive s c
ope s ofprac
tic
e pu rs u ant to
writte n jobd e s c
riptions .

H illC orre c
tionalC e nte rope ne d in O c
tobe r1986as ne w c
ons tru c
tion. Sinc
e that tim e , the fac
ility
has be e n we llm aintaine d . T he he althc
are u nit (H C U )is alarge , we ll-lighte d and we llm aintaine d
bu ild ing. T he re is am od e rate s ize d inm ate waitingare ane arthe e ntranc
e , as we llas am e d ic
ation
ad m inistration wind ow and offic
e r
s s tation. Fu rthe rin the H C U is the ou tpatient nu rs ings tation,
rad iology s u ite , d e ntalc
linic
, alarge m e d ic
ation/storage room , thre e we ll-e qu ippe d e xam ination
room s , an optom e try c
linic
, am e d ic
alre c
ord s d e partm e nt, alarge we ll-e qu ippe d u rge nt c
are room ,
a15-be d infirm ary and m u ltiple offic
e are as .
T he intras ys te m proc
e s s was re viewe d by u s throu gh 10 re c
ord re views , of whic
h two we re
proble m atic
. O ve rall, this was one ofthe be tte rproc
e s s e s we have s e e n. Follow u pwas aproble m
in two ofthe 10c
as e s .
Patient #1
T his is a52-ye ar-old who arrive d at H illon 2/19/14withahistory ofhype rte ns ion, apre viou s ly
tre ate d pos itive T B s kin te s t and ale ft ne c
k m as s fortwo ye ars alongwithas e izu re d isord e r. H e
had ahype rte ns ion c
linicon 3/11/14and at that point, his blood pre s s u re was in good c
ontrol. H e
was s u ppos e d to be re c
e ivingblood pre s s u re c
he c
ks twic
e we e kly, bu t two tim e s the s e c
he c
ks
we re c
anc
e lle d d u e to aloc
kd own. It is not c
le arwhy s om e one
s blood pre s s u re c
annot be take n
within the hou s ingu nit d u ringaloc
kd own. H e has ne ve rhad follow u pofhis s e izu re d isord e ror
his ne c
k m as s .
Patient #2
T his is a49-ye ar-old who arrive d at H illC orre c
tionalC e nte ron 3/27/2014. H e had hype rte ns ion,
he patitis C and c
irrhos is. O n 4/22, he had his bas e line c
hronicc
are c
linicforhe patitis bu t he has
ne ve rhad ahype rte ns ion c
linic
. H is hype rte ns ion m e d ic
ations have ru n ou t as of4/27.
M ay 2014
H illC orrec ti
onalC enter
P age 6
Nursing Sick Call

T he fac
ility u s e s a s c
he d u le d s ic
k c
all re qu e s t s lip s tyle s ic
k c
all s ys te m for both ge ne ral
popu lation and s e gre gation inm ate s . Sic
kc
allis c
ond u c
te d s e ve n d ays awe e k. R e qu e s t s lips are
available in e ac
hhou s ingu nit. W he n the inm ate c
om ple te s the re qu e s t, he plac
e s it d ire c
tly into
aloc
ke d m e d ic
ald rop-box loc
ate d in e ac
hhou s ingu nit. Se c
u rity s taffworkingthe 11:00p.m . to
7:00a.m . s hift c
olle c
ts the re qu e s ts and d e live rs the m to the he althc
are u nit. A re giste re d nu rs e
(R N )workingthe 11:00p.m . to 7:00a.m . s hift re views e ac
hs lipforrou tine ve rs u s u rge nt he alth
c
are ne e d s . Ifthe R N d e te rm ine s the re qu e s t is of an u rge nt natu re , the inm ate is im m e d iate ly
e valu ate d . If the R N d e te rm ine s the re qu e s t is of arou tine natu re , the inm ate is s c
he d u le d for
nu rs ings ic
kc
allon the following7:00a.m . to 3:00p.m . s hift. T his m e ans inm ate s are e valu ate d
within 24 hou rs of s u bm iss ion of the ir re qu e s t. D e partm e nt of C orre c
tions O ffic
e of H e alth
Se rvic
e s approve d tre atm e nt protoc
ols are u s e d for e ac
h nu rs ing s ic
k c
all e nc
ou nte r. T he
protoc
ols are on apre -printe d form and provid e apathway oftre atm e nt bas e d on inm ate provid e d
inform ation and phys ic
alfind ings. N u rs ings ic
kc
allc
ou ld be c
ond u c
te d by e ithe r aR e giste re d
N u rs e (R N )or Lic
e ns e d P rac
tic
alN u rs e (LP N ). P e r ID O C polic
y, allnu rs ings taffare initially
traine d by a phys ic
ian on appropriate u s e of the tre atm e nt protoc
ols and re traine d annu ally.
A d d itionally, e ac
h fac
ility phys ician is re qu ire d to re view two m e d ic
al re c
ord s pe r nu rs ing
provid e rm onthly forthe appropriate ne s s ofu s e ofthe protoc
ols . T he D ire c
torofN u rs ing(D O N )
c
ond u c
ts am onthly au d it ofnu rs ings ic
kc
allre c
ord s and m aintains aprotoc
olu s age log.
Se gre gation s tatu s inm ate s are offe re d d aily s ic
k c
all e qu ivale nt to the ge ne ral popu lation.
Se gre gation s tatu s inm ate s s u bm it s ic
kc
allre qu e s ts e ithe r to an offic
e r or nu rs ings taff. T he
re qu e s ts are c
olle c
te d by s e c
u rity s taffworkingthe 11:00p.m . to 7:00a.m . s hift and d e live re d to
the H e alth C are U nit. T he R N workingthe 11:00 p.m . to 7:00 a.m . s hift re views e ac
h s lip to
d e te rm ine u rge nt ve rs u s rou tine he althc
are re qu e s ts . U rge nt re qu e s ts are ad d re s s e d im m e d iate ly.
Inm ate s withre qu e s ts d e te rm ine d to be ofanon-u rge nt natu re are s c
he d u le d to be e valu ate d on
the im m e d iate ly following7:00a.m . to 3:00p.m . s hift. Sic
kc
alls lips c
an als o be give n to nu rs ing
s taffwhe n the y are in the u nit form e d ic
ation ad m inistration orthe d aily we llne s s c
he c
ks .
In the s e gre gation u nit the re is ad e s ignate d s ic
kc
all room that both nu rs ings taff and the
phys ic
ian u s e to c
ond u c
t s ic
kc
all. T he room is e qu ippe d withan e xam ination table , and nu rs ing
s tafftake s othe re qu ipm e nt and s u pplies ne e d e d fors ic
kc
all. T he nu rs e provid e s alist ofinm ate
nam e s to the s e gre gation u nit wingoffic
e r who the n take s inm ate s one -by-one to the s ic
kc
all
room for the nu rs e to e valu ate . A s a re s u lt, the inm ate be ne fits from a private , c
onfid e ntial
e nc
ou nte rwiththe be ne fit ofan appropriate e xam ination ifind ic
ate d . A gain, the O ffic
e ofH e alth
Se rvic
e s approve d protoc
h s ic
kc
all e nc
ou nte r. T he s ic
kc
all e nc
ou nte r is
d oc
u m e nte d in e ac
hd e taine e
s m e d ic
alre c
ord . A d d itionally, nu rs ings taffare re qu ire d to s ign in
and ou t ofthe s e gre gation u nit. T he D O N m aintains as e gre gation log.
Se gre gation we llne s s c
he c
ks are c
ond u c
ted foreac
hinm ate d aily on the 7:00a.m . to 3:00p.m .
s hift. N u rs ings taffad m iniste ringm orningm e d ic
ation proc
eed s c
e ll-to-c
e lltalkingwithe ac
h
M ay 2014
H illC orrec ti
onalC enter
P age 7
inm ate in s e gre gation s tatu s . D oc

u m e ntation of the we llne s s c
he c
k is note d on e ac
h inm ate
s pe c
ificflow s he e t. W he n the inm ate is re le as e d from s e gre gation, the flow s he e t is file d in the
inm ate m e d ic
alre c
ord . A d d itionally, the D O N m aintains as e gre gation log.
T e n ge ne ralpopu lation m e d ic
alre c
ord s we re re viewe d fors ic
kc
alle nc
ou nte rs oc
c
u rringd u ring
Fe bru ary, M arc
horA pril2014. T he 10re c
ord s ac
c
ou nte d for20nu rs ings ic
kc
alle nc
ou nte rs with
the followingd e tails .
1. O f the 20 s ic
kc
alle nc
ou nte rs , 11 we re pe rform e d by are giste re d nu rs e and nine we re
pe rform e d by alic
e ns e d prac
tic
alnu rs e .
2. O fthe 20e nc
ou nte rs , 10re s u lte d in are fe rralto e ithe rthe phys ic
ian orm id -le ve lprovid e r,
one phys ician c
ons u ltation at the tim e ofthe e nc
ou nte rand one te m porary plac
e m e nt in
the infirm ary u ntilthe phys ic
ian c
ou ld e valu ate the patient the ne xt m orning.
3. In e ac
h of the 10 re fe rrals , the appointm e nt oc
c
u rre d on the d ay s c
he d u le d , and the
phys ic
ian orm id -le ve lprovid e rad d re s s e d the iss u e that le d to the re fe rral.
4. O fthe 10 re fe rrals , s ix oc
c
u rre d on the s am e d ay orno late rthan the ne xt, one oc
c
u rre d
within two d ays , two oc
c
u rre d within thre e d ays and one oc
c
u rre d within five d ays .
5. In all20e nc
ou nte rs , the pre -printe d protoc
olform was u s e d , agood history and d u ration
we re d oc
u m e nte d , vital s igns we re re c
ord e d and e xam inations as ind ic
ate d we re
d oc
u m e nte d .
Five s e gre gation s tatu s inm ate m e d ic
alre c
ord s we re re viewe d from the s am e tim e pe riod . T he five
re c
ord s ac
c
ou nte d fors ix s ic
kc
alle nc
ou nte rs withthe followingd e tails .
1. O fthe s ix e nc
ou nte rs , thre e we re pe rform e d by are giste re d nu rs e and thre e by alic
e ns e d
prac
tic
alnu rs e .
2. O f the s ix e nc
ou nte rs , thre e re s u lte d in are fe rral to e ithe r the phys ic
ian or m id-le ve l
provide r.
3. In two ofthe re fe rrals , the patient was e valu ate d the s am e d ay, and in one ofthe re fe rrals ,
the patient, withac
om plaint ofd ry, itc
hy s kin, was e valu ate d in five d ays .
4. In alls ix e nc
ou nte rs , the pre -printe d protoc
olform was u s e d , agood history and d u ration
we re d oc
u m e nte d , vital s igns we re re c
ord e d and e xam inations as ind ic
ate d we re
d oc
u m e nte d .

T he re are 637 inm ate s e nrolle d in the c
hronicd ise as e c
linicin 773 s e parate c
linic
s . T his is
approxim ate ly 34% ofthe popu lation at H C C . T he d istribu tion in c
linic
s is as follows :
C ard iac
D iabe te s (73)
Ge ne ralM e d ic
ine (173)
H IV Infe c
tion/A ID S (15)
M ay 2014
H illC orrec ti
onalC enter
P age 8
Live r(57)
T B infe c
tion (7)
U nlike othe r fac

ilities , patients at H C C have allc
hronicd ise as e s ad d re s s e d at e ac
hc
hronicc
are
visit. T he only e xc
e ption to this prac
tic
e is patients withH IV whos e d ise as e is not followe d by any
ofthe ons ite provide rs . P atients withm ore than one c
hronicd ise as e are e nrolle d in what the y c
all
m u lti-c
linic
. T he c
hronicd ise as e nu rs e d e ve lope d his own form forthis pu rpos e and it has be e n
ad opte d by s om e ofthe othe rfac
ilities as we ll.
T he c
hronicc
are nu rs e at H C C is one ofthe m os t highly organize d and c
om pe te nt c
hronicc
are
nu rs e that we have m e t to d ate. H e has d e ve lope d and u s e s am u ltipage E xc
e ls pre ad s he e t for
trac
kingallthe c
linic
s . H e is d e vote d to the program fu ll-tim e and d oe s not get pu lle d to othe r
tas ks . H e knows the patients we ll, d oe s allthe s c
he d u lingand c
oord inate s allthe labs , te le m e d ic
ine
appointm e nts , rou tine phys ic
ale xam s and T B tre atm e nt. H e has arrange d m and atory e d u c
ational
s e s s ions forthe poorly c
ontrolle d d iabe tic
s and plans to d o anothe rs u c
hs e s s ion withinm ate s who
we re s u c
c
e s s fu lat c
hangingthe irlife s tyle s as gu e s t s pe ake rs .
ord s ofpatients e nrolle d in the c
linic
. R ec
ord re view s howe d ac
ons iste nt lac
k
ofe valu atingm e d ic
ation c
om plianc
e , and are lu c
tanc
e to ad ju s t m e d ic
ation whe n blood pre s s u re s
we re le s s than we llc
ontrolle d . Give n that patients are typic
ally only s e e n e ve ry fou r m onths for
the irc
hronicd ise as e s , this e xpos e s the m u nne c
e s s arily to the d e le te riou s e ffe c
ts ofhype rte ns ion
withthe pote ntialrisk ofe nd organ d am age . E xam ple s follow.
Patient #1
tion, he patitis C and hype rte ns ion who was ad m itte d to
ID O C in 2007 and has be e n at H C C s inc
e at le as t 2012 whe n his c
u rre nt volu m e be gins . H is
c
hronicc
are ove rthe pas t ye aru nfold e d as follows .
linicwithablood pre s s u re of130/92. T he phys ic
ian
d oc
u m e nte d no s u bje c
tive inform ation. C ontrolis rate d as fair bu t no m e d ic
ation c
hange s we re
m ad e . T he m e d ic
ord (M A R )re view s hows that the patient d id not pic
kup
his m e toprololin Ju ne , bu t this d oe s not appe arto have be e n re c
ognize d by the provide r.
linic
. H is blood pre s s u re was we llc
ontrolle d at 118/76.
T he M A R s hows he d id not pic
k u phis m e toprololin O c
tobe r.
O n 1/27/14, he was s e e n in H IV c
linic
. H is blood pre s s u re initially was 162/100;on re c
he c
k it was
156/100and the n 146/98. H e s aw no one in follow u pofthis.
linic
. H is blood pre s s u re was 110/82. T he M A R s hows he
d id not pic
k u phis am lod ipine in D e c
e m be r.
M ay 2014
H illC orrec ti
onalC enter
P age 9
O n 4/12, he was involve d in an alte rc

ation and plac
e d in s e gre gation. O n 4/13, anu rs e d oing
s e gre gation rou nd s note d that the patient had e xc
e s s ive am ou nts ofallhis m e d ic
ations in his c
e ll
and re fe rre d him to the d oc
torto d isc
u s s m e d ic
ation c
om plianc
e . T he phys ician s aw him the ne xt
d ay bu t d id not ad d re s s the m e d ic
ation c
om plianc
e iss u e . H is blood pre s s u re that d ay was 142/80.
Opinion:W he n c
onfronte d withle s s than ad e qu ate ly c
ontrolle d blood pre s s u re , the provide rfaile d
to inte rve ne . It appe ars that m e d ic
ation nonc
om plianc
e plays as ignific
ant role in this patient
s
inc
ons iste nt blood pre s s u re c
ontrol, bu t this is goingu nre c
ognize d and /or u nad d re s s e d by the
c
linic
ian.
Patient #2
T his is a48-ye ar-old d iabe ticwith hype rte ns ion and m orbid obe s ity who has be e n inc
arc
e rate d
s inc
e 1999 and trans fe rre d to H C C in 2010. H is proble m list has not be e n u pd ate d s inc
e 2012.
C hronicc
are ove rthe pas t ye arwas as follows .
O n 5/3/13, he was s e e n in m u lti-c
linic
. H is blood pre s s u re was 140/90and is rate d as fairbu t no
c
hange s in m e d ic
ations we re m ad e .
H e was not s e e n by aprovid e ragain u ntilthe ne xt m u lti-c
linicin Se pte m be r. H is blood pre s s u re
was 146/92, rate d as fairbu t no c
hange s m ad e .
O n 12/1, the patient was m ove d to s e gre gation and it was d isc
ove re d that he had m u ltiple c
ard s of
blood pre s s u re m e d ic
ations in his prope rty. H is m e d ic
ations we re the n nu rs e d ispe ns e d . T he M A R s
re fle c
t that he c
ons iste ntly re fu s e d his hyd roc
hlorothiaz id e bu t was c
om pliant with othe r
m e d ic
ations . H e re qu e s te d to d isc
ontinu e the hyd roc
hlorothiaz id e and was s e e n by the nu rs e
prac
titione rforthis on 12/24. H is blood pre s s u re was 170/98. T he nu rs e prac
titione rd id s topthe
hyd roc
hlorothiaz id e bu t m ad e no othe r m e d ic
ation ad ju s tm e nts . She ord e re d blood pre s s u re
c
he c
ks .
linic
. H is blood pre s s u re was 178/94. B lood pre s s u re c
he c
ks
from 12/31to d ate we re 140/84, 178/94, 150/90. T his was rate d as fairc
ontroland the d oc
torm ad e
no m e d ic
ation c
hange s .
O n 1/11, the patient was s e e n at nu rs e s ic
kc
allforhype rte ns ion. H is blood pre s s u re was 170/104
and 170/102; on re c
he c
k it was 160/90. H e was not re fe rre d to a provide r d e s pite be ing
s ym ptom aticwithhe ad ac
he .
O n 2/28, at 4:50 p.m ., he was again s e e n at nu rs e s ic
kc
allfor hype rte ns ion. H e c
om plaine d of
he ad ac
he and blu rre d vision. H is blood pre s s u re was 210/126. T he nu rs e prac
titione rwas c
ontac
te d
and ord e re d aone -tim e d os e ofc
lonid ine . H is blood pre s s u re c
am e d own to 162/96at s om e tim e
the re afte r, bu t e xac
tly whe n is not c
le ar. H e was re le as e d to his u nit withno follow-u p. H e has not
be e n s e e n again as ofthe d ate ofou rvisit 5/8.
M ay 2014
H illC orrec ti
onalC enter
P age 10

s blood pre s s u re has not be e n ad e qu ate ly ad d re s s e d . H e has be e n e xpos e d to
the d am aginge ffe c
ts of hype rte ns ion c
ons iste ntly for the pas t ye ar. Se ve re ly e le vate d blood
pre s s u re with s ym ptom s of he ad ac
he and blu rre d vision is ahype rte ns ive c
risis and s hou ld be
m anage d in am onitore d s e ttings u c
has an e m e rge nc
y d e partm e nt.
Patient #3
T his is a53-ye ar-old m an withas thm a, d iabe te s and hype rte ns ion who arrive d in ID O C on 3/13/14
and was trans fe rre d to H C C on 4/7/14. H e was s e e n in m u lti-c
linicon 4/20/14. H is blood pre s s u re
was 142/88, whic
hwas inac
c
u rate ly rate d as good and no c
Diabetes
A t the tim e of ou r re view, the re we re 23 patients whos e d iabe te s was u nd e r poor c
ontrol. T his
re pre s e nts 31.5% ofalld iabe ticpatients at this fac
ility, whic
his ave ry highnu m be r. To his c
re d it,
the c
hronicc
are nu rs e trac
ks the s e patients s e parate ly and has d e ve lope d and im ple m e nte d s pe c
ial
ed u c
ationalprogram s forthe s e patients .
ord s ofpatients with inad e qu ate d iabe te s c
ontrol. A gain, the the m e was a
non-aggre s s ive approac
hto m e d ic
ation titration withlonginte rvals be twe e n visits , thu s e xpos ing
patients to the d am aginge ffe c
ts of e le vate d blood glu c
os e . Fou r of the five patients we re not
m anage d withthe inte ns ity that the ir poor c
ontrolre qu ire d . T he fifthpatient had ju s t arrive d at
H C C am onthago, s o apatte rn was not ye t e vid e nt.
Patient #4
T his is a36-ye ar-old type 1d iabe ticwho was ad m itte d to ID O C in 2007and trans fe rre d to H C C
on 9/23/13. H e is pre s c
ribe d anon-phys iologicins u lin re plac
e m e nt re gim e n c
ons istingofN P H
twic
e ad ay and s lid ings c
ale ins u lin withm e als . A t the pre viou s fac
ility, he was pre s c
ribe d Lantu s
and s lid ings c
ale ins u lin bu t was s u m m arily s witc
he d to N P H u pon trans fe rto H C C . H e is not on
as tatin.
H e has be e n s e e n fre qu e ntly forhis poorly c
ontrolle d d iabe te s , withad ju s tm e nts to the N P H whic
h
have m ad e no d iffe re nc
e in his blood glu c
os e , whic
hhas c
ontinu e d to tre nd u pward .
Opinion:T ype 1 d iabe tic
s s hou ld be give n phys iologicins u lin re plac
e m e nt with abas al/bolu s
re gim e n. Switc
hingto N P H was inappropriate and has had ad e le te riou s e ffe c
t on the patient
s
d iabe te s c
ontrol. T his is plac
inghim at high risk for an ad ve rs e ou tc
om e . C u rre nt gu ide line s
re c
om m e nd s tatin the rapy foralld iabe tic
s.
Patient #5
T his is a56-ye ar-old m an withd iabe te s , hype rte ns ion and as thm awho was ad m itte d to ID O C in
1983and trans fe rre d to H C C in 2009. H e is not on as tatin. H is c
hronicc
are ove rthe pas t ye arhas
be e n as follows .
linicwithpoorly c
ontrolle d d iabe te s (A 1cof10.5% )and his
glipizid e was inc
re as e d .
M ay 2014
H illC orrec ti
onalC enter
P age 11
O n 6/12 and 7/17, he was s e e n in M D SC for follow u pofA c

c
u C he c
ks , whic
hwe re re as onably
we llc
ontrolle d .
O n 9/19, he was s e e n in m u lti-c
linic
. H is d iabe te s was u nd e rpoorc
ontrolwithan A 1cof11.9% .
T he d oc
torinc
re as e d his glipizid e .
H e was not s e e n again u ntil1/16/14at m u lti-c
linicwhe n his d iabe te s was s tillpoorly c
ontrolle d
withan u nc
hange d A 1c
. T he nu rs e prac
titione rre c
om m e nd e d s tartingins u lin, bu t patient wante d
to think abou t it. She re qu e s te d follow u pin two we e ks .
W he n s he s aw him again on 1/30, he d id not want to start ins u lin bu t rathe rwante d to d e c
re as e his
c
arbintake and e xe rc
ise m ore . H e had not be e n s e e n again as ofthe d ate ofou rvisit.
Opinion: A c
onc
e rte d e ffort s hou ld be u nd e rtake n to work withthis patient m ore c
los e ly in ord e r
to get his d iabe te s u nd e rbe tte rc
ontrols o as to d e c
re as e the risk ofan ad ve rs e ou tc
om e .
Patient #6
T his is a48-ye ar-old d iabe ticwithhype rte ns ion, hype rlipid e m iaand hypothyroid ism who arrive d
in ID O C in 2004and was trans fe rre d to H C C on 11/26/13.
O n 12/17, the patient was s e e n in m u lti-c
linic
. H is A 1cwas 8.4% on 11/1 and the N P H was
inc
re as e d .
O n 1/7/14, he was s e e n for his annu al m u lti-c
linic
. T he re we re no ne w labs bu t the nu rs e
prac
titione rinc
re as e d the N P H in re s pons e to e le vate d finge rs tic
ks . H e has not be e n s e e n s inc
e.
Opinion: T his patient s hou ld be s e e n m ore fre qu e ntly in ord e r to get his d iabe te s u nd e r be tter
c
ontrol.
Patient #7
T his is a48-ye ar-old d iabe ticwith hype rte ns ion and m orbid obe s ity who has be e n inc
arc
e rate d
s inc
e 1999 and trans fe rre d to H C C in 2010. H is proble m list has not be e n u pd ate d s inc
e 2012.
C hronicc
are ove rthe pas t ye arwas as follows .
O n 5/3/13he was s e e n in m u lti-c
linic
. H is A 1cwas 10.9on 4/29. T he nu rs e prac
titione rs pe nt a
s u bs tantialam ou nt oftim e e xploringhis d ietary habits and c
ou ns e linghim on d iet and e xe rc
ise .
She inc
re as e d his ins u lin.
H e was not s e e n by aprovide ragain u ntilthe ne xt m u lti-c
linicin Se pte m be r. H is A 1cwas 10%
on 8/28and ac
knowle d ge d as poorc
ontrolbu t no c
Fou rm onths late r, he was s e e n on 1/7/14in m u lti-c
linic
. H is A 1cwas 9.6% on 12/10, whic
hwas
note d to be poor bu t the only plan was ad vise d we ight, e xe rc
ise . H is d iabe te s has not be e n
ad d re s s e d again as ofthe d ate ofou rvisit.
M ay 2014
H illC orrec ti
onalC enter
P age 12
Opinion: T his patient s hou ld be s e e n m ore fre qu e ntly for d iabe te s m anage m e nt to m inim ize his
e xpos u re to e le vate d blood glu c
os e .
General Medicine
T he re we re s ix patients on C ou m ad in at the tim e ofou rvisit, allofwhom we re c
u rre ntly in the
the rape u ticrange and had large ly re m aine d s o throu ghou t the c
ale nd arye ar. T he c
hronicc
are nu rs e
ke e ps an e xc
e lle nt flow s he e t, whic
htrac
ks patients labre s u lts , c
linicd ate s , fre qu e nc
y ofblood
d raws and ou t d ate s .
W e note d that one of the patients ([redacted]) has be e n on C ou m ad in s inc
e 2001 whe n he
d e ve lope d aright lowe r e xtre m ity D V T followingafrac
tu re ofthe tibia. H e althc
are s taff have
d oc
u m e nte d that the re was no history of re c
u rre nt D V T , ye t he re m ains on the rapy. A s ingle
e pisod e ofprovoke d D V T re qu ire s only s hort-te rm antic
oagu lation (3-6m onths ). T he risks ofthis
m e d ic
ation m ay ou twe ighthe be ne fits at this late d ate ;the rapy s hou ld be re e valu ate d .
HIV Infection/AIDS
ord s (30%)ofpatients e nrolle d in the c
linic
. R ec
ord re view s howe d that m os t
patients we re s e e n tim e ly in the H IV te le m e d ic
ine c
linicand m os t labs we re d one tim e ly. H owe ve r,
the e le c
tronics te thos c
ope was ofte n not fu nc
tioningand the ID c
ons u ltant re lied on the patient
s
re port ofm e d ic
ation c
om plianc
e , whe n ou rre view ofthe M A R s ofte n c
ontrad ic
te d the s e re ports .
A s is tru e in allofthe othe rfac
ilities that we have visite d , the ons ite provid e rs have nothingto d o
withany as pe c
t ofH IV c
are , inc
lu d ingm onitoringm e d ic
ation c
om plianc
e and tole rability. In ou r
opinion, the provide rs lac
k offam iliarity withthe s e patients and the provide rs lac
k offam iliarity
withH IV d ise as e its e lfplac
e s the patients at u nne c
e s s ary risk ofad ve rs e ou tc
om e .
Patient #8
tion, he patitis C and hype rte ns ion who was ad m itte d to
ID O C in 2007and has be e n at H C C s inc
e at le as t 2012, whe n his c
u rre nt volu m e be gins . R e c
ord
re view s hows that the e le c
tronics te thos c
ope was not fu nc
tioningat thre e of the las t five ID
te le m e d ic
ine visits , and that the re we re d isc
re panc
ies be twe e n his re porte d m e d ic
ation c
om plianc
e
and that re fle c
te d on the M A R s . Fore xam ple , on 11/5/13, he was s e e n in H IV c
linicand re porte d
100% m e d ic
ation c
om plianc
e , bu t the M A R s hows he d id not pic
k u p his A triplain Se pte m be r.
Like wise , at the 1/27/14H IV c
linicvisit, he re porte d 100% m e d ic
ation c
om plianc
e , bu t the M A R
s hows that he d id not pic
k u phis A triplain Janu ary.
O n 4/12/14, he was involve d in an alte rc
ation and plac
e d in s e gre gation. T he ne xt d ay, anu rs e
d oings e gre gation rou nd s note d that the patient had e xc
e s s ive am ou nts ofallhis m e d ic
ations in his
c
e lland re fe rre d him to the d oc
torto d isc
u s s m e d ication c
om plianc
e . T he d oc
tors aw him the ne xt
d ay bu t d id not ad d re s s the m e d ic
ation c
om plianc
e iss u e .
M ay 2014
H illC orrec ti
onalC enter
P age 13
Opinion: T he re s e e m s to be ad isc
re panc
y be twe e n the patient
s re porte d c
om plianc
e rate and that
whic
h the M A R re fle c
ts . T his s hou ld be brou ght to the atte ntion of the provid e r s o it c
an be
d isc
u s s e d withthe patient d u ringthe visit.
Patient #9
T his is a51-ye ar-old m an withhype rte ns ion and H IV infe c
tion who arrive d in ID O C on 12/5/13
and trans fe rre d to H C C on 1/29/14. H e has be e n s e e n twic
e in ID te le m e d ic
ine c
linics inc
e his
arrivaland the e le c
tronics te thos c
ope was not fu nc
tioningfor e ithe r visit. O the rwise , labs have
be e n d one tim e ly and his d ise as e is we llc
ontrolle d .
Patient #10
tion whos e c
are is c
om plic
ate d by his nonc
om plianc
e
withlabs , visits and m e d ic
ations . H e was las t s e e n in H IV c
linicin Janu ary 2012, at whic
htim e
the ID s pe c
ialist had alongd isc
u s s ion withthe patient, im pre s s ingu pon him the d ire natu re ofhis
ne e d to s tart m e d ic
ations give n his low C D 4 c
ou nt and le ve lofvire m ia. T he patient was u tterly
u nwillingto take A R V s or e ve n B ac
trim . H e was offe re d m u ltiple opportu nities to s e e the ID
d oc
tor, bu t he has be e n re fu s inge ve r s inc
e . H e d id have labs d one on 4/3/14, whic
h s howe d a
fu rthe r d e c
line in his C D 4 c
ou nt to 38 and arise in his viral load to ove r 100K . T he fac
ility
phys ic
ian s igne d this labbu t m ad e no e ffort to d isc
u s s this withthe patient.
T he ID s pe c
ialist re c
om m e nd e d a ps yc
hiatrice valu ation, thou gh he ad m itte d that the patient
s e e m e d to be c
apable ofd e c
ision m aking. T his re c
om m e nd ation was ne ve rfollowe d , thou ghthe re
is anote d ate d 4/8/12labe le d m e ntalhe althc
hart re view.It state s only, M e ntalhe althfollow
u ponly as ind ic
ate d oras ne e d e d at this tim e ,and d oe s not s pe ak to the c
onc
e rns raise d by the
ID d oc
tor.
Opinion: A d m itte d ly, this is ad iffic
u lt c
as e . H owe ve r, atte m pts s hou ld be m ad e by one of the
ons ite provide rs to d e ve loparapport withthis patient in ord e rto fos te ran atm os phe re oftru s t that
m ight be c
ond u c
ive to ac
c
e ptanc
e ofthe rapy.
Patient #11
tion who e nte re d ID O C in 2011and arrive d at H C C two
we e ks late r. H e is tre atm e nt nave and has be e n offe re d the option ofthe rapy bu t c
hos e s to fore go
for now, as the ne e d to tre at is not u rge nt. H e has be e n s e e n tim e ly in ID c
linic(five tim e s s inc
e
A pril2013)withlabs d one tim e ly be fore e ac
hvisit. T he e le c
tronics tethos c
ope was not fu nc
tioning
at fou rofthe five visits . H e has not be e n s e e n by aloc
alprovide rs inc
e Ju ne 2011.
Opinion:T his patient s hou ld be s e e n period ic
ally by afac
ility provide rforthe s ake ofc
ontinu ity.
Pulmonary Clinic
W e re viewe d thre e rand om c
harts of patients with as thm a. T his lim ite d re view raise d qu e s tions
abou t the ac
c
u rac
y ofas s e s s ingd ise as e c
ontrol. O ne patient
s as thm awas d e e m e d to be u nd e rgood
c
ontrolat s e ve ralc
linicvisits withou t any historic
alinform ation to bas e this c
onc
lu s ion on.
M ay 2014
H illC orrec ti
onalC enter
P age 14
In anothe rc
as e , apatient was rate d as good c
ontrold e s pite u s inghis re s c
u e inhale rtwic
e e ac
hd ay.
W e s u gge s t the C Q I program e valu ate this iss u e in m ore d e tail.
Seizure Clinic
T he re we re no patients rate d as poorly c
ontrolle d in the s e izu re c
linic
.W e c
hos e to re view the fou r
who we re rate d as fairc
ontrol. A c
om m on the m e was inad e qu ate m onitoringortitration ofantis e izu re m e d ic
ations as d e s c
ribe d in the followingc
as e s .
Patient #12
T his is a33-ye ar-old m an withs e izu re s who was re c
e ive d in N R C on 2/20/14on D e pakote and
D ilantin. H is intake labs s howe d alow D ilantin le ve lof6, and athe rape u ticD e pakote le ve lof
51.3. H is m e d ic
ation was not c
hange d . H e was trans fe rre d to H C C on 3/4on the s am e d os e s .
O n 3/23, he had awitne s s e d s e izu re and m u ltiple d os e s ofD ilantin and D e pakote we re retrieve d
from his c
e ll. T he M e d ic
alD ire c
torwas c
ontac
te d and ord e re d that his m orningd os e ofD e pakote
be give n and to hou s e him in the infirm ary. Late rthat e ve ning, he had anothe rwitne s s e d s e izu re ,
the n anothe r that night. T he re is no e vid e nc
e that the nu rs e s c
ontac
te d the d oc
tor. T he M e d ic
al
D ire c
tors aw the patient the ne xt d ay and d isc
harge d the patient bac
k to the u nit. H e d id not ord er
ad ru gle ve lorm ake the m e d ic
ation nu rs e -ad m iniste re d .
titione r in s e izu re c
linic
. T he re we re no ne w labs s inc
e the intake
labs in Fe bru ary. She note d the bre akthrou ghs e izu re s bu t rate d him as fairc
ontrol. She inc
re as e d
the D ilantin and ord e re d ale ve lin one m onth.
Late rthat e ve ning, he had anothe rs e izu re . T he d oc
torwas c
alle d and ord e re d him plac
e d in the
infirm ary bu t the re we re no othe rord e rs . H e s aw the patient the ne xt d ay and d isc
harge d him to
his c
e llwithale ve lpriorto ne xt c
linic
, bu t d id not s pe c
ify whe n the ne xt c
linics hou ld be .
O n 4/24, his labs we re d rawn. T he labc
alle d the ne xt d ay withac
ritic
alD ilantin le ve lof33.2.
T he d oc
torwas c
alle d and ord e re d the m e d ic
ation be he ld forfive d ays , the n re s u m e d at the s am e
d os e withare pe at le ve l. Late rthat m orning, the nu rs e prac
titione rs aw the patient, who told he r
that he had be e n takingthre e c
aps u le s a d ay ins te ad of two. She ord e re d the m e d ic
ation be
ad m iniste re d d os e -by-d os e pe r he r note bu t d id not write this on the ord e r s he e t and ind e e d , the
M A R d oe s not re fle c
t that he was ge ttingthe m e d ic
ation nu rs e ad m iniste re d .
O n 4/29, ac
od e 3 was c
alle d to the u nit for s e izu re s . T he nu rs e
s note state s that the M e d ic
al
D ire c
torwas ons ite bu t the re is no note from him , only ord e rs forblood le ve ls ofbothd ru gs and
that the m orningD ilantin and D e pakote d os e s be give n, the n re s u m e d at the prior d os e . A gain,
m u ltiple d os e s of his s e izu re m e d ic
ations we re re c
ove re d from his c
e ll(108 d os e s total). T he
patient was plac
e d in the infirm ary. T hat afte rnoon, he had anothe rs e izu re and was give n 2m gof
A tivan forwhat sou nd s like apos tic
tals tate (s le e ping, s noringlou d ly, d rooling).
T he M e d ic
al D ire c
tor s aw the patient the ne xt d ay and d isc
harge d him bac
k to his u nit. T he
pre viou s ly d rawn d ru gle ve ls we re not ye t re viewe d by the d oc
tor, thou ghthe y we re re s u lte d that
M ay 2014
H illC orrec ti
onalC enter
P age 15
m orning. T he D e pakote le ve lwas u nd e te c

table and the D ilantin le ve lwas s u bthe rape u ticat 4.7.
T he s e we re s igne d by the d oc
toron 5/1, bu t no c
hange s we re m ad e and the patient had not be e n
s e e n in follow-u pas ofou rvisit on 5/8. R e view ofthe M A R s hows that the m e d ic
ations we re m ad e
d os e -by-d os e on 4/29and that he has be e n large ly c
om pliant s inc
e the n.
s m e d ic
ation has not be e n m onitore d ortitrate d appropriate ly. D e s pite be ing
ad m itte d to the infirm ary m u ltiple tim e s , he has be e n d isc
harge d be fore gainingc
ontrolof his
s e izu re s and e ns u rings tability.
Patient #13
T his is a28-ye ar-old m an withs e izu re s who was ad m itte d to ID O C on 11/18/08and trans fe rre d
to H C C on 12/24/13 on no s e izu re m e d ic
ations . H is D ilantin was d isc
ontinu e d at the pre viou s
ins titu tion, d u e to him be ings e izu re -fre e forye ars withle ve ls that we re s u bthe rape u ticthe m ajority
ofthe tim e .
H e was s e e n in s e izu re c
linicon 2/5/14and re porte d havingas e izu re two we e ks prior. T he re is
no othe rd oc
u m e ntation ofthis in the c
hart. T he d oc
torre s u m e d the D ilantin bu t d id not ord e ra
le ve l.
O n 2/17, the patient had as e izu re , was give n ad os e of A tivan and plac
e d in the infirm ary. A
D ilantin le ve lwas not obtaine d . T he d oc
tors aw him the ne xt d ay, inc
re as e d his D ilantin d os e and
d isc
harge d him to his c
e llhou s e . H e d id not ord e rad ru gle ve l.
O n 2/20, the patient had anothe rwitne s s e d s e izu re . A fte rward , he ad m itte d to s kippinghis D ilantin
d os e that m orning;howe ve r, this was not s u bs tantiate d by the M A R , whic
hs hows that he took the
d os e and that he had be e n c
om pliant withne arly allpre viou s d os e s . H e was plac
e d in the infirm ary
and the phys ic
ian was notified . T he re we re no ne w ord e rs and no note by the phys ic
ian. H e was
re le as e d by the R N the ne xt m orningwith no e vid e nc
e that the c
as e was d isc
u s s e d with the
phys ic
ian.
O n 3/4, the M e d ic
alD ire c
tor s aw the patient for d and ru ff. T he re was no m e ntion ofthe re c
e nt
s e izu re ac
tivity.
linic
. H is D ilantin le ve lwas 8.4on 3/27and he re porte d s kipping
s om e d os e s of the m e d ic
ation. M A R s hows that he m iss e d 11 d os e s in M arc
h. N o m e d ic
ation
c
O n 5/8, the re is anote from the LP N s tatingthat the patient has be e n re fu s inghis a.m . D ilantin
d os e s inc
e 4/20. H e is s c
he d u le d to s e e the M e d ic
alD ire c
toron 5/28.
s D ilantin was not ad e qu ate ly m onitore d arou nd the tim e ofhis bre akthrou gh
s e izu re s . N o m e aningfu lm anage m e nt of his s e izu re d isord e r oc
c
u rre d d u ringe ithe r of his two
s hort s tays in the infirm ary. T his patient
s nonc
om plianc
e ne e d s to be ad d re s s e d tim e ly;he willbe
m iss ingd os e s forne arly s ix we e ks by the tim e he s e e s the d oc
tor.
M ay 2014
H illC orrec ti
onalC enter
P age 16
Patient #14
T his is a53-ye ar-old m an withs e izu re s who has be e n inc
arc
e rate d s inc
e 2003and trans fe rre d to
H C C in 2010. A t the A u gu s t 2012 c
hronicc
are visit, the patient
s D e pakote le ve l was
s u bthe rape u tic
. T he re was no d oc
u m e ntation ofwhe n the patient
s las t s e izu re was . T he M e d ic
al
D ire c
tor the n d e c
re as e d the patient
s d os e with no c
linic
alrationale d oc
u m e nte d . H e was s e e n
re gu larly in c
hronicc
are c
linicthrou ghou t 2013 withou t bre akthrou gh s e izu re s , thou gh his
D e pakote le ve lwas c
ons iste ntly s u bthe rape u tic
.N o c
hange s to his d os e we re m ad e .
O n 1/24/14, he had as e izu re witne s s by his c
e llie. H e was plac
e d in the infirm ary fora23-hou r
obs e rvation and the d oc
torwas c
ontac
te d . H e ord e re d the D e pakote d os e be inc
re as e d from 500to
1000 m gpe rd ay. N o blood work was ord e re d . H e was re le as e d from the infirm ary the ne xt d ay
by ve rbalord e rfrom the M e d ic
alD ire c
tor.
linicby the nu rs e prac
titione r. T he D e pakote le ve l was
s u bthe rape u ticat 40.8. N o m e d ic
ation c
hange s we re m ad e . M A R s s how c
om plianc
e withthe gre at
m ajority ofd os e s .
Opinion:C ons ide rad ju s tingthis patient
s m e d ic
ation d os e in light ofthe priors e izu re ac
tivity.
B os we llP harm ac
e u tic
als , loc
ou nte r
m e d ic
ations for the fac
e ns e d as a W hole s ale D ru g D istribu tor/P harm acy
e is afax and fills ys te m whic
hm e ans patient ne w pre s c
riptions faxe d to
the pharm ac
y by 11:00a.m . willarrive at the fac
riptions faxe d by
10a.m . willbe re c
e ive d the ne xt d ay. T wo loc
alretailpharm ac
ies orthe loc
alhos pitalare the bac
ku ppharm ac
y forobtainingm e d ic
ation whic
k.
P atient s pe c
ificpre s c
riptions , s toc
k pre s c
riptions and c
ontrolle d m e d ic
ations arrive pac
kage d in a
30-d ay bu bble pac
k. O ve r-the -c
ou nterm e d ic
. T he
m e d ic
ation pre paration/storage are ais s taffe d withone fu ll-tim e pharm ac
y te c
hnic
ian, and B os we ll
provide s ac
ons u ltingpharm ac
ist to c
om e on-s ite onc
ription ac
tivity, to
as s e s s pharm ac
y te c
hnic
ian pe rform anc
e and te c
hniqu e and to d e stroy ou td ated orno longe rne e d e d
c
ontrolle d m e d ic
ations pu rs u ant to the re qu ire m e nts ofthe Fe d e ralD ru gA d m inistration (FD A )and
D ru gE nforc
e m e nt A ge nc
tion ofthe m e d ic
ation pre paration/storage are are ve ale d
alarge , c
le an, organize d , we ll-lighte d and we ll-m aintaine d are a. A n inte rview withthe pharm acy
te c
hnic
ian re ve ale d aknowle d ge able ind ivid u alwithtwe lve ye ars workingas the he althc
are u nit
pharm ac
y te c
hnic
ian. Ins pe c
ated tight ac
c
ou ntingofc
ontrolle d m e d ic
ations ,
both stoc
k and retu rn ite m s , ne e d le s /syringe s , s harps /ins tru m e nts and m e d ic
altools . A rand om
ins pe c
tion ofperpetu alinve ntories and c
ou nts ind ic
ated allwe re c
orre c
t. A d d itionally, ins pe c
tion
ofthe perpetu alinve ntories and c
ou nts in the infirm ary m e d ic
ation room ve rified allwe re c
orre c
t.
T hos e inve ntories are ve rified e ac
hs hift by on-c
om ingand off-goinginfirm ary nu rs ings taff.
M ay 2014
H illC orrec ti
onalC enter
P age 17
A c
c
pharm ac
y te c
hnic
ian. N u rs ingad m inistration and the pharm ac
y te c
hnic
ian are re qu ire d to d raw
ke ys to the irare aat the be ginningofe ac
hs hift and re tu rn the ke ys whe n le avingat the e nd ofthe ir
s hift. In the e ve nt the y wou ld le ave ins titu tionalgrou nd s with the ke ys , the y are c
ontac
te d by
arm ory pe rs onne lto im m e d iate ly re tu rn to the ins titu tion. N u rs ings taffare pe rm itte d to pas s the ir
ke y rings from s hift to s hift. K e ys to the m e d ic
ation s torage room and loc
ke d c
abine ts are re stric
te d
to nu rs ingad m inistration, nu rs ings taff and the pharm ac
y te c
hnic
ian. K e ys to the bac
k s toc
k
vau lt are re s tric
te d to the he alth c
are u nit ad m inistrator and d ire c
tor of nu rs ing. R e frige rator
te m pe ratu re s are m onitore d and d oc
u m e nte d d aily.
A ll pre s c
riptions , c
ontrolle d m e d ic
re c
y te c
hnic
ians . O nc
e re c
e ive d and c
hof
e d in bac
k s toc
k are
ke d and re s tric
te d ac
c
inve ntories for all ite m s loc
ate d in the vau lt are ve rified we e kly by the H e alth C are U nit
A d m inistrator and D ire c
tor ofN u rs ing. M e d ic
ation c
arts are inve ntoried d aily and re s toc
ke d as
ne e d e d . T he c
ras hc
art inve ntory is ve rified we e kly orany tim e the plas tics e c
u rity s e alis broke n.
T he c
ontrolle d m e d ic
ation bac
k s toc
k pe rpetu al inve ntory is ve rified we e kly. T he pe rpe tu al
inve ntories forc
ontrolle d m e d ic
kare ve rified e ac
hs hift by an onc
D os e -by-d os e m e d ic
e ns e d nu rs ings tafftwo tim e s ad ay. Form orning
(7:30a.m . to 8:30a.m .)m e d ic
ation ad m inistration, inm ate s from hou s ingu nits one and thre e are
m ove d to the he althc
are u nit in m e d ic
ation line s , and nu rs ings taffgoe s to hou s ingu nits two, fou r
and s e gre gation and ad m iniste rs the m e d ic
ation d os e by d os e d ire c
tly from the inm ate s pe c
ific30d ay bliste r pac
k. For e ve ning(7:00 p.m . to 9:00 p.m .) m e d ic
ation ad m inistration, nu rs ings taff
goe s to allhou s ingu nits , one throu ghfou rand s e gre gation, and ad m iniste rs the m e d ic
ation d os e
by d os e d ire c
tly from the inm ate s pe c
ific30-d ay bliste rpac
k. Inm ate s re qu iringins u lin m ove to
the he althc
are u nit, at approxim ate ly 6:00a.m . and 4:00p.m . to re c
e ive the irins u lin priorto e ating.
N u rs ing s taff ad m iniste rs d ire c
ificbliste r pac
k and im m e d iate ly
d oc
u m e nts the ad m inistration orre fu s alon the patient s pe c
ificm e d ic
ord
(M A R ). P atients re fu s ingm e d ic
ation are re qu ire d to s ign are fu s alform at the tim e ofre fu s al.
Laboratory
Laboratory s e rvic
e s are provide d throu gh the U nive rs ity of Illinois-C hic
ago H os pital (U IC ).
N u rs ings taff d raw and pre pare the s am ple s for trans port to U IC . R e s u lts are e le c
tronic
ally
trans m itte d bac
k to the fac
ility, ge ne rally within 24hou rs vias e c
u re fax line loc
al
d e partm e nt. U IC re ports both to the fac
ility and the Illinois D e partm e nt of P u blicH e alth all
re portable c
u rre nt C linic
alLaboratory Im prove m e nt A m e nd m e nt (C LIA )waive r
c
e rtific
ate that e xpire s Janu ary 27, 2015, on file . T he re we re no re ports ofany proble m s withthis
s e rvic
e.
M ay 2014
H illC orrec ti
onalC enter
P age 18

ord s ofpatients s e nt offs ite u rge ntly in whic
htwo ofthe five re fle c
te d an
abs e nc
e ofad isc
harge s u m m ary. T his lac
k ofad isc
harge s u m m ary m ake s appropriate follow u p
m ore d iffic
u lt.
Patient #1
T his is a38-ye ar-old who arrive d at H illC orre c
tionalC e nte ron 4/14/14. H e had ahistory ofprior
c
oronary proble m s and hype rte ns ion, inc
lu d ingthe plac
e m e nt ofs te nts as we llas vitiligo. In fou r
d ays he had d e ve lope d c
he s t pain whic
hwas d e s c
ribe d as 9on as c
ale of10and he als o had nau s e a
and vom iting. H e was give n nitroglyc
e rin, whic
hwas ine ffe c
tive . A t that point, his blood pre s s u re
was 210/140 and he was d iaphore ticand pale . O xyge n and as pirin we re give n and he was
trans fe rre d to the loc
alhos pitalafte ran E K G was pe rform e d . T he E K G re ve ale d s inu s tac
hyc
ard ia
witharight bu nd le branc
hbloc
k. Late rin the afte rnoon, he was trans fe rre d from the loc
alhos pital
to M e thod ist H os pital. H is c
ard iacworku pwas ne gative and he was re tu rne d to the C orre c
tional
C e nte ron 4/19. A gain, no d isc
harge s u m m ary was available .
Patient 2
T his is a53-ye ar-old patient who d e ve lope d c
he s t pain rad iatingto his le ft pe ras te rnalare a. H e
was s e e n by the phys ic
ian. H is blood pre s s u re was 165/90and he was ad m itte d to the infirm ary
for obs e rvation. H e was give n nitroglyc
e rin and afte r one d ay he was d isc
harge d from the
infirm ary. H e had anothe r e pisod e of c
he s t pain on 1/13/14 and anothe r on 1/14, and he was
u ltim ate ly s e nt to the loc
alhos pitaland the n onto M e thod ist H os pital, whe re an angiogram was
pe rform e d s howingright c
oronary oc
c
lu s ion. Ste nts we re plac
e d and he was d isc
harge d the
followingd ay. H e s aw ac
ard iologist for afollow-u p visit on 1/20. O n 2/11, he had ac
ard iac
c
hronicc
are bas e line visit withou t the be ne fit of a d isc
harge s u m m ary or any follow-u p
re c
om m e nd ations from the hos pital.

W e re viewe d s e ve ralre c
ord s , inc
lu d ingpatients [redacted], [redacted], [redacted], and in
e ac
hofthe s e the patient pre s e nte d withc
he s t and e pigas tricpain and in e ac
hc
as e the patients we re
s e e n by anu rs e who ne ve rc
ontac
te d the phys ic
ian and ne ve rpe rform e d an E K G, in violation of
the re qu ire d proc
e d u re .

T he proc
e s s at the H illC orre c
tionalC e nte rc
ons ists ofac
linic
ian initiatingac
ons u lt re qu e s t and
this is the n d isc
u s s e d by the M e d ic
alD ire c
torat the c
olle gialre view. T he m e d ic
alre c
ord s pe rs on
d oe s partic
ipate and faxe s a list with the re qu e s t to W e xford . She ind ic
ate d s he s om e tim e s
sc
he d u le s the appointm e nts be fore s he re c
e ive s the au thorization nu m be r, whic
h d oe s not
ne c
e s s arily im m e d iate ly follow the ve rbalte le phone approval. Form os t appointm e nts , s he is able
to obtain an appointm e nt d ate within 30 d ays . T his inc
lu d e s bothc
e d u re s .
She is als o re s pons ible fornotifyingc
u s tod y ofthe appointm e nt d ate s . T he
M ay 2014
H illC orrec ti
onalC enter
P age 19
s pe c
ialists fillin the irportion ofthe re qu e s t form and this is brou ght bac
k to the prison by c
u s tod y,
who take s it to the nu rs e in the infirm ary. T his nu rs e re views it and take s any ne c
e s s ary ac
tions
and s e nd s ac
opy to m e d ic
alre c
ord s ;the y willinitiate any follow u p re c
om m e nd e d . Ifc
olle gial
re view d e te rm ine s an alte rnate plan ofc
are is ind ic
ate d , the patient is s u ppos e d to be brou ght bac
k
to the c
linic
ian to be inform e d . H owe ve r, in ou rreview this d id not always happe n. In fac
t, the re
we re s om e visits , e s pe c
ially with the M e d ic
alD ire c
tor, within the re qu ire d tim e fram e whe re it
d oe s not appe arthat the alte rnative plan ofc
are was in fac
t d isc
u s s e d . W e re viewe d 11re c
ord s and
id e ntified s ignific
ant iss u e s in s ix ofthos e . M ost ofthe iss u e s re late d to lac
k oftim e ly follow-u p,
inc
lu d ings low phys ic
ian re ac
tion to u ltras ou nd re s u lts s u gge s tingpos s ible tu m ors in the live r.
Patient #1
T his is 34-ye ar-old withno c
hronicproble m s . T his patient was s e e n on 1/9/14, and was fou nd to
have alu m pin his te stic
le . A n u ltras ou nd ofthe te stis was re c
om m e nd e d and approve d and on 2/5,
the u ltras ou nd re ve ale d a1.4c
m s olid right e pid idym alm as s . O n 2/11, this find ingwas d isc
u ssed
withthe patient and two blood te sts we re ord e re d , bothofwhic
hwe re ne gative . T he s e we re als o
d isc
u s s e d withthe patient. A GU c
ons u lt was re qu es te d on 3/4and this was s c
he d u le d on 3/18. T he
ge nitou rinary s pe c
ialist d iagnos e d an inflam m atory m as s and re c
om m e nd e d an antibioticbe give n
and forthe patient to retu rn in s ix we e ks . T he follow-u pvisit ne ve rhappe ne d .
Patient #2
T his is a29-ye ar-old withm ye lone u ropathy. O n 2/20/14, the patient was s e nt ou t foran E M G of
the right hand . T he c
linic
ian had obs e rve d m u s c
le was tingin the right hand on 2/7/13. O n 1/7/14,
an M R I ofthe ne c
k re ve ale d no bas is forthe rad ic
u lopathy. A ne u ros u rge ry c
ons u lt was re qu e s te d
and this was approve d and pe rform e d at U of I. A n E M G of the right arm pe rform e d by a
s u bs pe c
ialist was re c
om m e nd e d and approve d . T he E M G ind ic
ate d the find ings we re c
ons iste nt
witham u ltifoc
alm otorne u ropathy. T he re c
om m e nd ation was that the patient ne e d e d as pe c
ific
GM I antibod y te s t whic
hs hou ld be d one at W as hington U nive rs ity M e d ic
alSc
hool. T he s pe c
ialist
ind ic
ate d this proble m c
ou ld re s u lt in d isability, bu t it als o m ay be tre atable . T his proble m had not
be e n followe d u p, bu t the H e althC are A d m inistratorc
ontac
te d the hos pitaland arrange m e nts will
be m ad e to s e nd the patient ou t.
Patient #3
T his is a24-ye ar-old withc
hronicle ft m id -abd om inalpain for4-5ye ars . O n 11/13/13, d isc
u s s ions
we re had withthe patient re gard ingalowe rGI and an u ppe rGI alongwithabd om inalC T e xam .
T he c
olle gialre view initially re c
om m e nd e d we ight los s . B oththe bariu m e ne m aand the u ppe rGI
we re ne gative , alongwiththe C T s c
an ofthe abd om e n. T he c
linic
ian re c
om m e nd e d s e nd ingthe
patient to GI, bu t the c
olle gialre view d e c
id e d that this patient s hou ld be m onitore d ons ite . T he
patient was give n ale tte rabou t the c
hange in plan. H owe ve r, the le tte rwhic
hthis obs e rve r s aw
d oe s not appe arto be inte lligible to the ave rage inm ate .
Patient #4
T his is a56-ye ar-old who arrive d at H illon 3/29/13 withaprior pos itive tu be rc
u lin s kin te s t as
we llas he patitis C . O n 3/21/13, he we nt ou t foran u ltras ou nd ofthe abd om e n as re c
om m e nd e d
M ay 2014
H illC orrec ti
onalC enter
P age 20
by the he patitis C s pe c
ialist. T he u ltras ou nd s howe d m u ltiple m as s e s in the live r in D e c
e m be r
2013. T his was re viewe d by the phys ic
ian nine d ays afte rthe s e rvic
e was pe rform e d . O n 3/7/14,
the he patitis C s pe c
ialist s aw the patient and re c
om m e nd e d aC T s c
an. T he C T was d one on 3/21/14
bu t the re we re no C T re s u lts in the c
hart. T his patient has had an abnorm alu ltras ou nd fors e ve ral
m onths whic
hno one ac
te d on. T he s e c
ou ld have be e n tu m ors . Fortu nate ly, we obtaine d the C T
re s u lts whic
h s howe d that the y are like ly he m angiom as of the live r, whic
h are in fac
t be nign.
H owe ve r, this patient is fortu nate that d e s pite the abs e nc
e offollow u p, his he althis probably not
in je opard y. T his is apartic
u larly proble m aticc
as e give n the d e lay in ac
tion by the phys ic
ian.
Patient #5
T his is a44-ye ar-old withhype rlipid e m ia, hype rtens ion and c
hronickid ne y d ise as e . T his patient
was s e nt for an e c
hoc
ard iogram on 4/11/14, and this proc
e d u re was be ingd one to ru le ou t
pu lm onary hype rte ns ion. T his was re c
om m e nd e d by ne phrology. T he re port s hows inje c
tion
frac
tion of70% and m ild le ft ve ntric
u larhype rtrophy, alongwithd ias tolicd ys fu nc
tion and m ild
m itralre gu rgitation. T he re has be e n no follow-u pvisit withthe patient. In ad d ition, the e c
ho re port
was not d ic
tate d u ntilone we e k afte rthe s e rvic
e was provide d . T his is an u nac
c
e ptable d e lay.
Patient #6
hronicproble m s who was s e nt ou t on 4/18/14foran E M G and ne rve
c
ond u c
tion stu d y ofthe right le g. In M arc
h2014, he was c
om plainingofbu rningand apu llingpain
in his right le gwhic
hhad be e n pre s e nt foraye ar. H e was re fe rre d to the phys ic
ian on 3/4/14. Lab
te sts were ord e red , whic
hwe re norm al. E M G was approve d throu ghc
olle gialre view on 3/25. E M G
was d one on 4/18, and re ve ale d s pasticparapare s is, s u gge stive ofac
e ntralne rvou s s ys te m le s ion
in the thorac
ics pine . T he re was anorm alne u roc
ond u c
tion stu d y ofthe right lowe re xtre m ity. A n
M R I ofthe s pine was the n re c
om m e nd e d . T his was approve d and perform e d on 4/25. T he M R I
re port re ve als d iscfragm e nts and d iscprotru s ion c
au s ingas te nos is ofthe le ft ne u ralforam e n. T he re
has be e n no follow u pby the phys ic
ian withthe patient.
In re viewings e ve ralc
as e s that re s u lte d in alte rnative plans ofc
are , we c
ou ld not find , fors e ve ral
ofthe m , any d isc
u s s ion be twe e n the phys ic
ian and the patient abou t the c
hange in plan.
Infirmary Care
onfigu re d as thre e , fou r-be d room s and thre e s ingle be d room s .
T he thre e s ingle be d room s are fu nc
tioningne gative airpre s s u re re s piratory isolation room s . T he re
is anu rs e c
all s ys te m withabu tton on the wallabove e ac
hbe d he ad board that whe n pu s he d
provide s bothavisu aland au d ible alarm . In the e ve nt the patient
s m e d ic
alc
ond ition pre ve nts him
from be ingable to pu s hthe wallm ou nte d bu tton, be d s id e c
alllight c
ord s are available as ne e d e d .
M ay 2014
H illC orrec ti
onalC enter
P age 21
T he u nit is s taffe d withat le as t one re giste re d nu rs e 24hou rs ad ay, s e ve n d ays awe e k whe ne ve r
the infirm ary is oc
c
u pied . Se c
u rity s taffthat is as s igne d to the he althc
are u nit pe rform s rou tine
rou nd s throu ghthe infirm ary.
Inm ate porte rs perform allthe janitoriald u ties in the infirm ary. W he n as s igne d to the he althc
are
u nit, e ac
h porte r is re qu ire d to re c
e ive trainingon blood -borne pathoge ns , infe c
tiou s d ise as e s ,
bod ily flu id c
le an-u p, prope r s anitation of infirm ary room , be d s , fu rnitu re and line ns and
c
onfid e ntiality of m e d ic
al inform ation. T he training is c
ond u c
te d by the H e alth C are U nit
A d m inistrator, and e ac
hinm ate /porteris re qu ire d to s ign-offas havinghad the trainingand s ign a
writte n he althc
are u nit porte rjobd e s c
ription. A d d itionally, e ac
hporte ris offe re d the H e patitis B
vac
c
ine s e ries .
A n infirm ary d aily re port and m ove m e nt logis m aintaine d whic
hlists the nam e and nu m be r of
e ac
hpatient in the infirm ary, s tatu s , fore xam ple ac
u te , c
hronic
,c
risis watc
h, e tc
., d iagnos is, d iet,
labte s ts , ad m iss ion d ate and tim e , d isc
harge d ate and tim e and c
om m e nts . A n infirm ary d aily
ac
tivity re port is als o m aintaine d whic
hd e tails the nam e , nu m be r, d iagnos is, loc
ation and d ate s
ad m itte d and d isc
harge d from ou ts ide hos pitals , patients goingou ts id e the fac
ility forou tpatient
s e rvic
es, c
om m u nity hos pital e m e rge nc
y room oc
c
u rre nc
e s , on-s ite s pe c
ialty c
linic
s and any
d e aths .
T he D O N re porte d an ave rage d aily c
e ns u s of8-11 patients with1-3 be ingon ac
u te c
are s tatu s
and the re m aind e rbe inge ithe rc
hronicc
are , hou s ingand te m porary plac
e m e nt.
It s e e m s that the m ajority of the infirm ary ad m iss ions are not ac
tu ally ad m iss ions bu t 23-hou r
obs e rvations . W e le arne d that obs e rvations d o not re qu ire ad oc
tor
s ord e rto re le as e ;thou ghID O C
e nc
ou rage s this, it is not re qu ire d by polic
y. T his c
ou ld ac
c
ou nt forthe re lative ly low c
e ns u s in the
infirm ary.
A t the tim e ofou rvisit, the re we re e ight patients ad m itte d to the infirm ary, two ofwhom we re on
m e ntalhe alth watc
he s . T he re was one ac
u te patient;the re s t we re e ithe r c
hronicad m iss ions or
hou s ingas s ignm e nts . T he ac
u te ad m iss ion ([redacted])is a46-ye ar-old m an ad m itte d on 4/22/14
withan intra-artic
u larfrac
tu re ofthe le ft d istaltibiatre ate d withan e xte rnalfixator. H e has be e n
s e e n tim e ly, inc
lu d ingonc
e forc
hronicc
are c
linic
.H e c
ons iste ntly c
om plains ofs e ve re pain rate d
as 8-10ou t of10, whic
hd oe s not appe arto be ad e qu ate ly tre ate d withthe c
ons e rvative m e d ic
ation
re gim e n he is pre s c
ribe d .
Infection Control
T he D ire c
torofN u rs ing(D O N )fu nc
tions as the fac
ility infe c
tion c
ontrolnu rs e . W he n re qu ire d ,
s he inte rfac
e s withthe C ou nty D e partm e nt ofP u blicH e althand the Illinois D e partm e nt ofP u blic
H e alth (ID P H ). T he D O N m onitors , c
om ple te s and s u bm its to ID P H allre portable c
as e s . Skin
infe c
u ltu re d and tre ate d . P er the D O N , the re is an
ave rage oftwo c
illin re s istant Staphyloc
oc
c
tions pe r
m onth.
M ay 2014
H illC orrec ti
onalC enter
P age 22
H e althC are U nit nu rs ings taffc

ond u c
tions in the d ietary
d e partm e nt and pe rform s pre -as s ignm e nt and annu alfood hand le r e xam inations for staff and
inm ate s to work in the d ietary d e partm e nt. N e gative air-pre s s u re re ad ings in the thre e re s piratory
isolation room s are m onitore d and d oc
u m e nte d e ac
hs hift. A tou rofthe he althc
are u nit, inc
lu d ing
the infirm ary, ve rified pe rs onalprote c
tive e qu ipm e nt (P P E )available to staffin allare as as ne e d e d .
tu re proofc
ontaine rs forthe
are u nit
om m e rc
m e d ic
om m u nic
annu ally.
T he u nit is c
le an, with the janitoriald u ties pe rform e d by inm ate porte rs . W he n as s igne d to the
he althc
are u nit, porte rs re c
e ive training, as provide d by the H e althC are U nit A d m inistrator, in the
proper s anitation ofinfirm ary room s , be d s , fu rnitu re and line ns , c
om m u nic
able d ise as e s , blood borne pathoge ns , bod ily flu id c
le an-u pand c
onfid e ntiality ofm e d ic
alinform ation. W e e kly, porte rs
are re qu ire d to was hd own withas olu tion ofwate r, soapand ble ac
hallthe walls in the infirm ary.
Followinge ac
hu s e , the infirm ary s howe r, walls and floor, are d isinfe c
te d withas olu tion ofwate r,
s oapand ble ac
h. H e althC are U nit porte rs lau nd e rthe infirm ary line ns in ahe althc
are u nit lau nd ry
room . A te s t ofthe was hingm ac
hine hot wate rtem pe ratu re ind ic
ate d ate m pe ratu re ofonly 125
d e gre e s F. T his te m pe ratu re is too low to as s u re the prope rc
le aningand s anitizingofpote ntially
bod y flu id s oile d be d line n.
A d d itionally, it was re porte d the hot water te m pe ratu re in the ins titu tionallau nd ry is rou tine ly
m e as u re d at 125d e gre e s F, whic
hagain is too low. In ord e rto prope rly s anitize , line ns are to be
e xpos e d to water at le as t 160 d e gre e s Ffor 25 m inu te s or give n able ac
h bathhavingan initial
s tartingc
onc
e ntration of100parts pe r m illion and ate m pe ratu re ofat le as t 140d e gre e s Fforat
le as t 10m inu te s .
T he im pe rviou s vinyl c
oatingon e xam ination s tools and table s and infirm ary m attre s s e s was
note d to be torn or c
rac
ke d , whic
h pre ve nts prope r s anitizingand allows for pote ntial c
ros s c
ed .
InmatesInterviews
Six ins u lin d e pe nd e nt inm ate s we re inte rviewe d . A ll s ix had be e n d iagnos e d s e ve ral ye ars
pre viou s ly, and alls ix we re knowle d ge able re gard ingthe ir c
hronicd ise as e . Six ofthe s ix we re
anc
e of the ir he m oglobin A 1cblood le ve l. Five of the s ix
e nt he m oglobin A 1cblood le ve l. A lls ix re porte d be inge valu ate d
by the phys ic
ian e ve ry 3-4 m onths and havingthe ability to pe rform blood glu c
os e m onitoring
prior to the ad m inistration of ins u lin. A ll s ix re porte d the y are inform e d of the ir m os t re c
e nt
he m oglobin A 1cle ve ld u ringe ac
hd iabe ticc
linic
. A llwe re ofthe opinion the m e d ic
ald ire c
tor
tries to d o agood jobm anagingthe ird iabe ticc
are .
M ay 2014
H illC orrec ti
onalC enter
P age 23
It was re porte d that bre akfas t is s e rve d be twe e n 5:00a.m . and 6:00a.m ., lu nc
his s e rve d be twe e n
10:15a.m . and 11:30a.m . and d inne ris s e rve d be twe e n 4:00p.m . and 5:30p.m . A lls ix inm ate s
s tate d that bre akfas t is always c
old c
e re al, white bre ad and as we e t roll. It was re porte d that
m orningins u lin is ad m iniste re d be twe e n 4:00a.m . and 5:00a.m ., and afte rnoon ins u lin be twe e n
3:15p.m . to 3:45p.m .
A lls ix inm ate s agre e d on the followingiss u e s .
1.
2.
3.
4.
5.
6.
7.
Se riou s lac
ise tim e
D iet is d iabe ticu nfriend ly;it is too highin c
arbohyd rate s and low in prote in
B ottom bu nk ord e rs are not au tom atic
ally provid e d to ins u lin d e pe nd e nt d iabe ticpatients
N o pod iatry c
are
Som e tim e s re c
e ive ins u lin priorto e atingand s om e tim e s afte re ating
E ve n thou ghhard c
arry
c
and y to s e lf-tre at low blood s u gar, s om e s e c
u rity s taffwilltake the c
and y d u ringrand om
s hake d owns ;polic
y is not c
ons iste nt.
Dental Program
Executive Summary
O n M ay 6-9, 2014, a c
om pre he ns ive re view of the d e ntal program at H e nry H ill C C was
c
om ple te d . Five are as ofthe program we re ad d re s s e d inc
c
e s s to tim e ly d e ntal
c
y ofthe
phys ic
al fac
ilities and e qu ipm e nt d e vote d to d ental c
are ;and 5) the ove rall d e ntal program
m anage m e nt. T he followingobs e rvations and find ings are provide d .
T he c
linicits e lfc
ons ists ofathre e c
hairs and u nits in thre e line arc
linicbays in alongc
linicare a.
T he s pac
e is ad e qu ate in s ize . T he c
hairs and u nits are approac
hing30ye ars old and are in m arginal
to poorc
ond ition. T he intra-oralx-ray u nit is old and in poorc
ond ition. T he c
abine try is s howing
we ar and c
orros ion. T he re is an ad joiningroom hou s ingthe d e ntallaboratory and s te rilization
are a. T he re is als o an ad joiningoffic
e for s taff. Ins tru m e ntation and e qu ipm e nt are ad e qu ate to
m e e t the ne e d s ofthis ins titu tion.
are d e live ry was an are aof c
onc
e rn. N o c
om pre he ns ive e xam ination and no
tre atm e nt plan pre c
ed ed c
om pre he ns ive c
are d e live ry. N o d oc
u m e nte d e xam ination of the s oft
tiss u e s norpe riod ontalas s e s s m e nt was part ofthe tre atm e nt proc
e s s . H ygiene c
are and prophylaxis
we re not provide d priorto re s torations . R e s torations at tim e s proc
e e d e d withou t appropriate intraoralrad iographs . O ralhygiene ins tru c
u m e nte d .
A d e ntalhygienist is not on s taffat H e nry H illC C . T his om iss ion ne e d s to be c
orre c
te d .
M ay 2014
H illC orrec ti
onalC enter
P age 24
A nothe r are aof c

onc
e e d from a
d oc
u m e nte d and ac
c
u rate d iagnos is. A d iagnos is or re as on for e xtrac
tion was s e ld om
d oc
u m e nte d . C u rre nt and ad e qu ate x-rays we re not always pre s e nt to proc
e e d with d e ntal
e xtrac
tions .
ons tru c
e ofc
are d e live ry inc
lu d e d in
the c
om pre he ns ive c
are proc
e s s . Sinc
e ac
om pre he ns ive e xam ination and tre atm e nt plan was ne ve r
part ofthe tre atm e nt proc
e s s , it was im pos s ible to d e te rm ine what pre -prosthe ticc
are was ne e d e d
and what was d one orle ft u nd one . P e riod ontalas s e s s m e nt and hygiene c
are we re ne ve rprovid e d .
O ralhygiene ins tru c
u m e nte d .
Inm ate s ac
c
e s s s ic
kc
kc
alls ign-u pe ve ry m orningin the u nits . Inm ate s with
u rge nt c
om plaints (pain and s we lling)are e nc
ou rage d to u s e d e ntals ic
kc
all. T he inm ate s are s e e n
that m orningfor atriage d e valu ation. U rge nt c
are ne e d s are ad d re s s e d at that tim e . O the rs are
re s c
he d u le d bas e d on le ve lofne e d . R ou tine c
are was not provide d at s ic
kc
all. T he s ys te m works
su c
c
e s s fu lly and inm ate s withu rge nt c
are ne e d s are s e e n in atim e ly m anne r. In none ofthe e ntries
was the SO A P form at be ingu tilize d norwas ad iagnos is pre s e nt.
Inm ate s re qu e s t rou tine c
are viathe inm ate re qu e s t form . T he s e inm ate s are s e e n and e valu ate d
within fou rto five d ays and plac
e d s e qu e ntially on the waitinglist. T he waitinglist forrou tine c
are
is 18 m onths longand is ofm ajorc
onc
e rn to inm ate s and ad m inistration alike . B e c
au s e inm ate s
are plac
e d bac
k at the e nd ofthe waitinglist afte rarou tine c
are appointm e nt, the y wait 18m onths
forthe irne xt appointm e nt. A s s u c
h, c
ontinu ity ofc
are was poor, e s pe c
ially withno hygienist on
s taff.
ord was not thorou ghand poorly d e ve lope d . T he re was
no s ys te m in plac
alc
alc
ons u ltation
orinte rve ntion priorto d e ntaltre atm e nt.
as ke d , the c
linic
ian ind ic
ate d that s he d oe s not rou tine ly take blood pre s s u re s on the s e patients .
T he s te rilization are awas s m alland s hare d with the d e ntallaboratory. Ste rilization flow was
s atisfac
tory. A lthou gh m os t ins tru m e nts we re bagge d and s te rilize d , alarge tray of u nbagge d
ins tru m e nts was in ac
abine t. T he ins tru m e nts we re be ingre m ove d one at atim e whe n ne e d e d for
d e ntaltre atm e nt. Slow s pe e d hand piec
e s we re s te rilize d and s tore d u nbagge d . A ls o, e xam ination
ins tru m e nts we re bagge d and s te rilize d in bu lk. Ins tru m e nts we re re m ove d from the ope ne d bag
one at atim e as ne e d e d . A llins tru m e nts s hou ld be bagge d and s te rilize d ind ivid u ally orin kits .
T he re was not abiohaz ard warnings ign in the s te rilization are a. Safe ty glas s e s we re not worn by
patients d u ringtre atm e nt. N o rad iation haz ard s igns we re poste d in the are awhe re x-rays are take n.
M ay 2014
H illC orrec ti
onalC enter
P age 25
Finally, bu lk s torage offille d biohaz ard m ate rials bags was m aintaine d in the d e ntalc
linicprope r
in two large ope n c
ard board boxe s on wood e n palle ts . T his is highly irre gu lar.
T he c
ontinu ing qu ality im prove m e nt program is inad e qu ate and poorly u tilize d . T he d e ntal
program s hou ld d e ve lops tu d ies and c
orre c
tive ac
ribe d in the
bod y ofthis re view.

H e nry H illC C has ad e ntals taffc
ons istingofone fu ll-tim e d e ntist and two fu ll-tim e as s istants .
D r. Jac
ks on works fou r10-hou rd ays . She is not in the c
linicon Frid ays . O ne ofthe as s istants als o
works the s am e hou rs . T he re is no hygienist on s taff. T his is as e riou s om iss ion, as hygiene s e rvic
es
and pe riod ontalthe rapy are e s s e ntialparts ofany d e ntalprogram . W ithou t this as pe c
t ofc
are , the
princ
iple s of c
om pre he ns ive c
are are violate d . T he re is little in the way of pre ve ntive s e rvic
es
offe re d . P re ve ntive c
are is an e s s e ntial as pe c
t of c
om pre he ns ive d e ntistry. R e s torations and
prosthe tic
s proc
e e d withou t ad d re s s ing pe riod ontal ne e d s and plaqu e c
ontrol. T he prim ary
obje c
tive ofd e ntalc
are is oralhe alth. W ithou t oralhygiene s e rvic
e s , this obje c
tive willne ve rbe
m e t. D r. Jac
ks on c
annot be e xpe c
te d at allto provid e the s e s e rvic
e s in am e aningfu lway. T his is
poor u s e of he r s kills and s he has not the tim e . She is m ore than bu s y ad d re s s ingm ore u rge nt
d e ntalne e d s .
T he c
u rre nt s taffingis not s u ffic
ient to m e e t the oralhe althne e d s ofthe inm ate popu lation at H ill
CC.
D r. Jac
ks on
sc
re d e ntials are on file and the e ntire d e ntals taffis c
e rtified in C P R .
Recommendations:
1. Im m e d iate ly hire ad e ntalhygienist to ad d re s s the hygiene s e rvic
e s and pre ve ntive as pe c
ts
ofthe d e ntalprogram .

T he c
linicc
ons ists ofthre e c
hairs and u nits in m arginalto poorc
ond ition. T he d e ntist u s e s two of
the s e u nits . T he s e u nits are the originalone s from whe n H illC C ope ne d in 1986, s o the y are
approac
hing30ye ars old . T he y are ve ry worn, torn and c
orrod e d . T he y are not u pto c
onte m porary
s tand ard s for d isinfe c
tion. R e plac
e m e nt ofthe s e thre e u nits is ind ic
ate d . T he re is no panore x in
this c
linic
. T he x-ray u nit is in s im ilarly old and poorc
ond ition. T he au toc
lave is rathe rne w and
fu nc
tions we ll. T he ins tru m e ntation is ad e qu ate in qu antity and qu ality. T he hand piec
e s are old e r
bu t we llm aintaine d and re paire d whe n ne c
e s s ary. T he c
abine try is rathe rold and s howingwe ar
and c
tionally O K . T his d oes m ake d isinfe c
tion of c
abine t s u rfac
e s m ore
d iffic
u lt and pote ntially c
om prom ise d .
T he c
linicits e lfc
arou nd e ac
hu nit is ac
c
e ptable . P rovide rand as s istant have ad e qu ate room to work, and none of
M ay 2014
H illC orrec ti
onalC enter
P age 26
the c
hairs inte rfe re with e ac
h othe r. T he re was as e parate s te rilization and laboratory room of
ad e qu ate s ize . It had as m allbu t ad e qu ate work s u rfac
c
om m od ate proper
infe c
tion c
orne rofthe room . T he
s taffhad as e parate room foroffic
e s pac
e . It was ad e qu ate in s ize withd e s ks and file c
abine ts . T he
fac
ility and e qu ipm e nt are ad e qu ate to m e e t the ne e d s ofH e nry H illC C
Recommendations:
1. R e plac
e the thre e d e ntald e live ry u nits and c
hairs in the m ain c
linicas s oon as pos s ible .
T he d e live ry ofs afe and e fficient d e ntalc
are is be ingc
om prom ise d . N e w u nits are d e s igne d
to m e e t c
onte m porary s tand ard s ofd isinfe c
tion and s afe ty.
2. R e plac
e the x-ray u nit, as it is ve ry old , c
u m be rs om e and ou td ate d .

hniqu e s and proc
e d isinfe c
tion was
tants we re be ing
u s e d . P rote c
tive c
es.
abine ts re ve ale d that m os t we re prope rly bagge d and
s te rilize d . T he re was atray ofalarge s tac
k ofwhat I was told we re s te rilize d ins tru m e nts that we re
not bagge d . T he y we re re m ove d from the tray one at atim e as ne e d e d for patient c
are . A ll
ins tru m e nts s hou ld be s te rilize d and bagge d . A llhigh-s pe e d hand piec
T he s te rilization flow from d irty to c
le an m e t ac
c
tion is always ne c
e s s ary, forpatient and provide r. A ls o, the re was no
warnings ign poste d whe re x-rays we re be ingtake n to warn ofpote ntialrad iation haz ard .

W e looke d bac
k thre e ye ars and fou nd the s te rilization logs to be in plac
e . T he y u tilize the C ros s te x
s ys te m from H e nry Sc
he in. T he y are notified ifane gative te s t is obtaine d . T he s te rilization are a
is s hare d withthe d e ntallaboratory. T he are ain ge ne ralwas old and ru s te d and rathe rd isorganize d .
P rope r s terilization flow from d irty to ste rile was in plac
e . Storage c
abine try was als o old and
c
orrod e d .
A n e xam ination and re view ofs te rilization proc
e d u re s re ve ale d that e xam ination ins tru m e nts we re
pac
kage d and s te rilize d in bu lk. T he whole s te rilize d pac
kage was the n ope ne d at the be ginningof
the d ay and ins tru m e nts re m ove d ind ivid u ally from this ope ne d bag. T his c
re ate s opportu nity for
c
ros s c
ontam ination. E xam ination kits s hou ld be c
re ate d and bagge d and s te rilize d ind ivid u ally.
A ls o, s traight and right angle hand piec
e s we re s te rilize d bu t not pac
kage d . T he s e hand piec
es
s hou ld be bagge d and s te rilize d ind ivid u ally.
M ay 2014
H illC orrec ti
onalC enter
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Su rprisingly, bu lk s torage of fille d biohaz ard m ate rialbags was m aintaine d in the d e ntalc
linic
proper, in two large , re d bagline d , ope n c
ard board boxe s on wood e n palle ts . T he s e we re in the
ope n c
linicare a, not in s e parate room orare a. T his is highly irre gu larand d oe s not c
om ply with
O SH A s tand ard s forbiohaz ard s torage .
N o rad iation haz ard warnings we re s e e n in the x-ray are aorin the c
linic
.
Recommendations:
1. T hat all ins tru m e nts and kits , inc
lu d ingall hand piec
e s , be ind ivid u ally bagge d be fore
s te rilization and not m aintaine d loos e and in bu lk.
3. A warnings ign be pos te d in the x-ray are ato warn ofrad iation haz ard s .
4. T hat the bu lk s torage offille d biohaz ard m ate rials bags be in as e parate room , away from
the c
linicare a, and that it m e e t allO SH A re qu ire m e nts fors u c
hs torage .
Comprehensive Care
tive tre atm e nt c
are proc
eed
u m e nte d intraand e xtra-oralc
om pre he ns ive e xam ination and awe ll
d e ve lope d tre atm e nt plan, to inc
lu d e all ne c
ord s
re ve ale d that no c
om pre he ns ive e xam ination was e ve r pe rform e d and no tre atm e nt plans
d e ve lope d . N o e xam ination of s oft tiss u e s or pe riod ontalas s e s s m e nt was part of the tre atm e nt
proc
e s s . H ygiene c
are and prophylaxis was ne ve rprovide d . H illC C has no hygienist on s taff. T his
is as e riou s om iss ion that willbe d isc
u s s e d in the s taffings e c
tion ofthis re port. T hos e re c
ord s with
an e xam ination ofhard tiss u e s had bite wingx-rays available . R e s torations we re provide d from a
panore x x-ray in five of the 13 patient re c
ord s reviewe d . T his rad iograph is not d iagnos ticfor
c
aries . Fu rthe r, oralhygiene ins tru c
ord as part of
the tre atm e nt proc
ess.
Recommendations:
u m e nte d
tre atm e nt plan.
tiss u e s .
3. In allc
aries .
4. H ygiene c
ess.
5. T hat c
e s and d e ntal
prophylaxis.
u m e nte d .
M ay 2014
H illC orrec ti
onalC enter
P age 28
Dental Screening
A lthou ghH e nry H illC C is not are c
e ption and c
las s ific
ation c
ord s to
ins u re the re c
e ption and c
las s ific
ation polic
tive 04.03.102,
sec
om plianc
e.
Extractions
u m e nte d
d iagnos is. In only thre e of the 10 re c
ord s e xam ine d was ad iagnos is or re as on for e xtrac
tion
inc
lu d e d as part of the d e ntal re c
ord e ntry. A d d itionally, all e xtrac
tions s hou ld proc
e e d from
c
u rre nt, ac
c
u rate and d iagnos ticx-rays . In fou rofthe 10re c
ord s this was not the c
as e . I re viewe d
five ad d itionalre c
ord s and fou nd this als o to be tru e for fou r ofthos e re c
ord s . T he s e are rathe r
s e riou s om iss ions in the s afe and c
orre c
t d e live ry of d e ntal c
are . D iagnos ticrad iographs are
e s s e ntial. E xtrac
tions withou t ad e qu ate rad iographs is risky, forpatient and d e ntist. C ons e nt form s
we re on file .
Recommendations:
tion be inc
be s t ac
c
ially fors ic
k-c
alle ntries .
d e ntal re c
ord inc
e as to why that
2. T hat allorals u rgic
alproc
e d u re s only proc
e e d withac
u rre nt d iagnos ticx-ray.
s s hou ld proc
ord e d on
ad d re s s e d prior to partiald e ntu re c
ons tru c
tion. Sinc
e ac
om pre he ns ive e xam and tre atm e nt plan
was ne ve r part ofthe tre atm e nt proc
e s s , it was im pos s ible to d ete rm ine what pre -prosthe ticc
are
was ne e d e d and what was d one orle ft u nd one . In only one ofthe five re c
ord s re viewe d ofpatients
re c
e iving re m ovable partial d e ntu re s we re oral hygiene ins tru c
tions provid e d . P e riod ontal
as s e s s m e nt was not d oc
u m e nte d in any of the re c
ord s , and no hygiene c
are was part of the
tre atm e nt proc
ess.
Recommendations:
1. A c
inc
lu d ing bite wing and /or pe riapic
al rad iographs and pe riod ontal as s e s s m e nt, s hou ld
pre c
e d e allc
are , inc
s.
2. T hat period ontalas s e s s m e nt and tre atm e nt be part of the tre atm e nt proc
e s s and that the
e ed ingwithim pre s s ions . T hat oralhygiene ins tru c
tion
M ay 2014
H illC orrec ti
onalC enter
P age 29
always be inc
lu d e d .
c
Dental Sick Call

Inm ate s ac
c
e s s d e ntals ic
kc
allthrou ghas ign-u pe ve ry m orningin the u nit. T his d e ntals ic
kc
all
list is give n to d e ntalthat m orningand allofthe inm ate s on the s e lists from the u nits are s e e n that
s am e m orningon the e m e rge nc
y d e ntalline . U rge nt d e ntalc
are has priority and inm ate s are ofte n
tre ate d that s am e d ay. O the rs are give n appointm e nts bas e d on the irne e d s . T his is agood s ys te m
and ve ry tim e ly in ad d re s s ingu rge nt c
are ne e d s . Se gre gation is d one the s am e way. T he s e
s e gre gation inm ate s are e s c
orte d and d o not ne e d to be s e gre gate d from the ge ne ralpopu lation. A
re view ofthe s e 10 re c
ord s re ve ale d that rou tine c
are was not be ingprovide d on s ic
kc
all. In all
c
as e s the c
om plaint was ad d re s s e d . In none ofthe e ntries was the SO A P form at be ingu s e d . N or
was any d iagnos is u s u ally provid e d .
Recommendation:
kc
s
c
hief c
om plaint is re c
ord e d and ad d re s s e d and that athorou ghfoc
d iagnos is pre c
Treatment Provision
e that prioritize s tre atm e nt ne e d s . Inm ate s have d aily s ic
kc
alls ign-u p
available and the s e inm ate s are s e e n the s am e d ay and are triage d and provide d c
are ac
c
ord ingly.
U rge nt c
are ne e d s are ad d re s s e d that d ay. O the rs are s c
he d u le d ac
c
ord ingly orplac
e d on the rou tine
tre atm e nt list. Inm ate s are be ings e e n in atim e ly m anne rand the iriss u e s ad d re s s e d .
Inm ate s c
are viathe d aily m ornings ic
kc
alls ign-u por, ifthe y fe e lthe y ne e d to
be s e e n im m e d iate ly, by c
ontac
tingH illC C s taff, who willthe n c
allthe d e ntalc
linicwith the
inm ate
s c
om plaints from
inm ate s withu rge nt c
are ne e d s (c
om plaint ofpain ors we lling)are s e e n at le as t by the following
workingd ay. M id-le ve lprac
om plaints .
T he y c
an provide ove rthe c
ation orc
allm e d ic
al/d e ntals taffifthe y fe e lm ore is
ne e d e d .
Inm ate s who s u bm it re qu e st form s for rou tine c
are are e valu ate d within 4-5 d ays and plac
ed
are . T he re is awaitinglist forrou tine c
are whic
his abou t 18
m onths longand awaitinglist fornon-u rge nt e xtrac
tions whic
his abou t 8m onths long. Inm ate s
who are s e e n for rou tine c
are are plac
e d bac
k at the e nd of the rou tine c
are list after e ve ry
appointm e nt. T he re fore, it is approxim ate ly 18 m onths be twe e n appointm e nts . C ontinu ity ofc
are
is im pos s ible in s u c
has ys te m , e s pe c
ially withalm ost no hygiene c
are available . Inm ate s c
om plain
abou t this s ys te m and d e ntalre c
e ive s abou t one inm ate grievanc
e e ve ry we e k. O the r d iffic
u lties
as s oc
iate d withrou tine c
are inc
lu d e the fac
t that the d e ntist works only fou rd ays pe r
M ay 2014
H illC orrec ti
onalC enter
P age 30
we e k. A ls o, the re is ac
ou nt e ve ry afte rnoon at 3:00p.m . Inm ate s are e xpe c
te d to be in the iru nit
by 2:45p.m . and c
ou nt is u s u ally ove rat 3:30p.m . To ac
c
om m od ate this inm ate non-m ove m e nt
c
ou nt, the finalappointm e nts forthe d ay are s c
he d u le d at 2:15p.m . T he s e two orthre e patients
are s e e n d u ringand afte rthe c
ou nt u ntil4:00p.m . T he las t 30to 45m inu te s are u s e d to c
le an, d o
ins tru m e nt c
ou nts and organize the c
linicforthe followingd ay. T he proc
e s s s e e m s ine ffic
ient and
probably c
ontribu te s to the le ngthofthe waitinglist. T he le ngthofthis list was am ajorc
onc
e rn
to inm ate s and ad m inistration.
Recommendations:
1. A lthou ghthe s ys te m s e e m s e qu itable , I s u gge s t that inm ate s take n offthe rou tine c
are list
be take n to c
om ple tion rathe r than be plac
e d bac
k at the e nd of the list be twe e n
appointm e nts . M u c
h be tte r c
ontinu ity of c
are c
an be ac
c
om plishe d and inm ate s m ay
pe rc
e ive that the y have am u c
hbe tte rc
hanc
e ofge ttingallofthe ird e ntalwork d one .
2. A hygienist s hou ld be hire d im m e d iate ly. It is an e s s e ntialpart ofthe d e ntalte am .
D e ntaliss u e s are not inc
lu d e d in the H e nry H illC orre c
tionalC e nte rO rientation M anu al
Recommendations:
1. T hat the d e ntalprogram inform ation re gard ingac
c
e s s to c
are ,type s ofc
are , and m anage m e nt
ofc
are be inc
lu d e d in the H e nry H illC C O rientation M anu al.

T he polic
ies and proc
e d u re s are ad e qu ate ly d e ve lope d and ad d re s s allofthe c
ritic
alare as . T he y
are ou t ofd ate and s hou ld be u pd ate d and prope rly e nd ors e d as s oon as pos s ible
Recommendations:
1. U pd ate and prope rly e nd ors e the d e ntalpolicies and proc
e d u re s in plac
e at H e nry H illC C .
Failed Appointments
A re view ofm onthly re ports and d aily work s he e ts re ve ale d afaile d appointm e nt rate ofle s s that
5% . T his is we llwithin an ac
c
e ptable range .

A re view ofthe d e ntalre c
ord s of inm ate s on anti-c
oagu lant the rapy fou nd that thre e ofthe s ix
m ad e no m e ntion ofthis at all. T he he althhistory s e c
ord is ve ry we ak and
M ay 2014
H illC orrec ti
onalC enter
P age 31
lac
ks s u ffic
ient d e tail. N one ofthe re c
ord s was red flagge d to attrac
t the im m e d iate atte ntion of
the provide r. T he m e d ic
al history in the d e ntals e c
tion is inc
ons iste nt in ide ntifyingm e d ic
ally
c
om prom ise d patients that m ay ne e d s pe c
ialc
ons id e rations and c
als taff
priorto d e ntaltre atm e nt.
linic
ians ind ic
Recommendations:
alhistory s e c
al
c
ialpre c
atc
ofthe provide r.
2. T hat blood pre s s u re re ad ings be rou tine ly take n on patients withahistory ofhype rte ns ion,
e s pe c
alproc
e d u re .
Specialists
D r. Jac
ks on s e ld om u s e s the s e rvic
e s ofac
om m u nity orals u rge on. She d oe s allofthe s u rge ries
he rs e lfin hou s e , inc
lu d ingim pac
te d third m olars and the e xc
ision ofs oft tiss u e le s ions . T his is a
c
om m e nd able s e rvic
e s he provid e s whic
h s ave s c
osts and ad d s to the s afe ru nning of the
ins titu tion. O rals u rge ry s e rvic
e s are available withagrou pc
alle d K as pe r and B olofc
hak, O S at
W e s te rn Illinois O raland M axillofac
ialSu rge ry in Gale s bu rg, IL.
Recommendations: N one .
Dental CQI
ontribu te s m onthly d e ntal c
ontac
t and prod u c
tion s tatistic
s to the C Q I
c
om m itte e . A C Q I-type s tu d y was d oc
u m e nte d as c
om ple te d in Janu ary of 2014. T he s tu d y
c
ons iste d oftrac
kingc
om ple te d re s torations and s e e inghow ofte n the toothe ve ntu ally ne e d e d to
be e xtrac
te d . T he thre s hold was d oc
u m e nte d as m e tand no follow-u pwas ne e d e d . It was abit
c
onfu s ingand not we lld e s igne d . M e aningfu ls tu d ies wou ld be foc
u s e d on the le ngthofthe waiting
list and on othe rprogram we akne s s e s .
Recommendations:
1. V italize and e xpand the C Q I proc
e s s by d e ve lopingongoingC Q I s tu d ies that ad d re s s the
we akne s s e s in the d e ntalprogram id e ntified in this re port. Im ple m e nt d e ve lope d polic
ies
and proc
e d u re s that are d ire c
te d toward the s e im prove m e nts .
Mortality Review
T he re we re five d e aths at H C C ove rthe past ye ar. O ne was as u ic
id e . O fthe othe rfou r, one was
trans fe rre d he re on hos pic
e form e tas taticlive rc
anc
e r, and one d ied ofe nd stage live rd ise as e bu t
M ay 2014
H illC orrec ti
onalC enter
P age 32
was followe d c
los e ly by D r. P au lat W e xford who was the m ain provid e r orc
he s tratinghis c
are
and no proble m s we re id e ntified . T he re m ainingtwo we re s e riou s ly proble m aticas d e s c
ribe d
be low.
Patient #1
T his was a48-ye ar-old m an who was ad m itte d to ID O C in 1984, arrive d at H C C in 2009having
qu it s m okingtwo ye ars prior and d ied oflu ngc
anc
e r on 1/30/13. H e be gan c
om plainingofle ft
ne c
k and c
he s t pain in Fe bru ary 2012 and wrote se ve ralle tte rs ofc
onc
e rn that his proble m was
not be ingd iagnos e d ortre ate d appropriate ly. In one s u c
hle tte rd ate d 4/11/12, he s tate s that, T his
m atte r has gotte n wors e the re is c
onvu ls ingpain in m y rib c
age whic
h has m y le ft rib c
age
protru d ingm ore than the right s ide .H e re qu e s te d to s e e aphys ic
ian not anu rs e .
T he firs t nu rs e s ic
kc
allnote is d ate d 5/8/12whe n he was s e e n at nu rs e s ic
kc
alls tating, I c
ou ghe d
u p blood and it
s from this inju ry to m y s hou ld e r. H e was re fe rre d to the M D on 5/15. O n that
d ate , he s aw the M e d ic
alD ire c
torfors e ve ralc
om plaints :joint pain, los s ofm u s c
le tone , (ille gible )
allove rthe bod y, u rinary s ym ptom s and we ight los s . C hart re view c
onfirm s that he had in fac
t los t
30pou nd s ove rthe pas t ye ar. T he d oc
tor
s as s e s s m e nt was m u ltiple joint pain & othe rc
om plaints .
Los s ofwe ight.H e ord e re d labs , an anti-inflam m atory and afollow-u pin two we e ks .
W he n he s aw the patient bac
k on 6/5, the patient c
om plaine d of le ft-s id e d c
he s t pain rad iating
d own the le ft arm , we ight los s , and s pittingu p thic
k s pu tu m . O n e xam the d oc
tor note d le ft
s u prac
lavic
u lar m obile < qu arte r s ize s we lling(ille gible ). H e re viewe d and ac
knowle d ge d that
the labs re ve ale d ane m ia. H e pu t the patient on iron and ord e re d ac
he s t x-ray and afollow-u pvisit.
T he c
he s t x-ray was d one that d ay and s howe d , A foc
alopac
ity in the le ft lowe rlobe withte nting
of the le ft he m i-d iaphragm . T his find ing is ne w...s u pe rim pos e d ac
u te infe c
tion c
annot be
e xc
lu d e d ... follow u pm ay be obtaine d .
alD ire c
tors aw the patient in follow u pofthe c
he s t x-ray re s u lts . H e note d that
the patient had m u ltiple c
om plaints bu t d id not e nu m e rate the m . V itals we re :133.5#, 133/78,
99.2, P 108, R 18. T he e xam was d oc
u m e nte d as be nign. H e ord e re d the patient s aline gargle s and
are pe at C B C afte r30d ays , the n follow u p.
al D ire c
tor s aw the patient in follow u p of the C B C . T he only s u bje c
tive
inform ation is d e nies ble e d ing. H is we ight was now 130 pou nd s . A be nign e xam was
d oc
u m e nte d . T he ane m iawas s lightly wors e . T he d oc
torinc
re as e d the iron, ord ere d an H IV te s t
and are pe at c
he s t x-ray in D e c
e m be r.
O n 7/27, the patient s u bm itte d agrievanc
e s tatingthat he had los t his voic
e on 5/26and that he had
s e e n the M e d ic
alD ire c
torm u ltiple tim e s bu t the d oc
torwas not d oinganythingabou t it. H e als o
s tated that he notic
e d alu m pon his ne c
k on 6/3and on 6/5pointe d it ou t to the d oc
tor, who s aid,
it
s not alym phnod e, it m ay be ac
ys t,ac
c
ord ingto the patient. H e re qu e ste d to be s e nt to an e ar
nos e and throat s pe c
ialist, and this lu m pbe tre ated forpos s ible c
anc
e rand re m ove d .
M ay 2014
H illC orrec ti
onalC enter
P age 33
O n 8/12, the patient wrote ale tte rto the W ard e n abou t his voic
e be ingou tforthre e m onths and
the lu m pon the le ft s id e ofhis ne c
k whic
hm ay orm ay not be c
anc
e rou s .
O n 8/15, the patient was brou ght to the c
linicto s e e the M e d ic
alD ire c
tor. T he patient re porte d
s pittingu p blood s inc
e 6/17, c
he s t pain s inc
e Fe bru ary, hoars e ne s s x 3 m onths , pain in the le ft
sc
apu lar are a, and c
ou ghingalot s inc
e M ay. H is we ight was 127 pou nd s . T he d oc
tor note d an
alm ond s hape m obile s we llingapp3.5c
m non-ind u rate d .H e ord ere d m ore labs and aZ-pac
k as
we llas an x-ray ofthe abd om e n.
O n 8/20, he pre s e nte d withhe m optys is and brou ght atiss u e withlarge am ou nt ofblood in it. T he
nu rs e note d his voic
e had ahars htone . She re fe rre d him to the d oc
torim m e d iate ly. T he only
s u bje c
tive inform ation the d oc
tord oc
u m e nte d was , s ays I am be tte rthan be fore .H e d oc
u m e nte d
anorm ale xam , as s e s s m e nt was follow u phe m optys isand plan was to arrange blood re s u lts ,
willfollow u p ac
c
ord ingly. T he labs ord e re d on 8/15 we re d rawn now and s howe d wors e ning
ane m ia.
O n 8/21, he pre s e nte d to the nu rs e at 9:00p.m . withle ft s hou ld e rand c
he s t pain. She plac
e d him
in the infirm ary for obs e rvation. T he R N s aw the patient at 3:00a.m . and note d that the patient
rate d his pain as e xtre m e and that his le ft s hou ld e r blad e appe are d d iffe re nt. T he M e d ic
al
D ire c
tors aw the patient on 8/22and note d that the patient s ays I am fine , I have this le ft s hou ld e r
pain offand on for1-2m onths .H e d oc
u m e nte d anorm ale xam and d isc
harge d the patient bac
k
to the u nit withnaproxe n and follow u pas ne e d e d .
O n 8/29, the patient was brou ght to the H C U in awhe e lc
hairbe c
au s e the pain in his le ft s id e was
s o s e ve re he was u nable to walk u pright. T he nu rs e note d that his phys iqu e is as ym m e tric
al, ve ins ,
m u sc
le m ore pronou nc
e d on le ft s id e ...s ke le tal m ore pronou nc
e d on le ft s id e ...I/M state s he
c
ou ghe d u p blood . T he M e d ic
al D ire c
tor s aw him the ne xt d ay and note d the le ft c
e rvic
al
ad e nopathy and now ne w le ft axillary ad e nopathy. H e ord e re d a re pe at c
he s t x-ray, s pu tu m
c
ytology and d isc
u s s e d the c
as e withD r. B ake ron an e m e rge nc
y bas is to get approvalforaC T
sc
an. H e als o s poke to apu lm onologist to arrange c
ons u ltation. T he patient was plac
e d in the
infirm ary.
T he C T s c
an was d one the ne xt d ay (8/31)and s howe d ave ry large c
arc
inom awhic
he xte nd s
throu ghthe s u pe riorportion ofthe le ft he m ithorax throu ghthe ape x and involve s the le ft ante rior
c
he s t e xte nd ing to the ante rior ple u ral s u rfac
e , and invad ing the m e d ias tinu m with tu m or
s u rrou nd ingthe as c
e nd ingthorac
icaorta, e xte nd ingalongthe aorticarc
h and e nc
irc
lingthe
proxim ald e s c
e nd ingthorac
icaorta. T he prim ary tu m or e xte nd s for at le as t 15 c
m ...[by]10.2
c
m ...by 9.2 c
m ...the re is c
irc
u m fe re ntial tu m or arou nd the le ft m ains te m bronc
hu s and which
e ngu lfs the le ft u ppe rlobe bronc
hiand proxim alle ft lowe rlobe bronc
hi. T u m orals o invad e s the
pe ric
ard iu m and pe ric
ard ialfat...and prod u c
e s m as s e ffe c
t u pon the m ain pu lm onary arte ry and
e nc
irc
le s the le ft pu lm onary tru nk alm os t c
om ple te ly oblite ratingthe lu m e n...the s u pe rior ve na
c
avais ante riorly d isplac
e d from bu lky ad e nopathy ...T he re is als o m as s e ffe c
t u pon the s u pe rior
poste riorm argin ofthe right atriu m by bu lky ad e nopathy ...
M ay 2014
H illC orrec ti
onalC enter
P age 34
T he C T re port was re c
e ive d by the ins titu tion on 9/4and d isc
u s s e d withthe patient the s am e d ay.
H e was s e e n by pu lm onology on 9/5, bu t c
le arly his c
as e was too farad vanc
e d foranythingothe r
than palliative tre atm e nt. H e c
ontinu e d to d e c
line u ntilhe d ied fou rm onths late r.
Opinion:T he blatant d isre gard forthis patient
s obviou s s ym ptom s ofs e riou s illne s s is s tu nning.
T he laps e s in c
are are s o nu m e rou s and s o e gre giou s it is hard to know whe re to s tart. P e rhaps at
the ons e t ofs ym ptom s , whic
htook thre e m onths to finally re s u lt in avisit withthe phys ic
ian?
B u t alas , at that visit and m u ltiple visits to follow, the d oc
tor e ithe r d isre gard e d or faile d to
re c
ognize the c
ons te llation ofs ym ptom s that we re highly ind ic
ative ofm alignanc
y. W hic
hofthe
two e xplanations is m ore d ange rou s is not c
le ar. Give n the m arke d d isc
re panc
ies be twe e n the
patient
s re porte d s ym ptom s as d oc
u m e nte d in his own word s and the nu rs e s note s , and the
d oc
tor
s ve rs ion of the s e s am e s ym ptom s as d oc
u m e nte d in his note s , we s u s pe c
t the form e r
e xplanation is m ore ac
c
u rate . In any e ve nt, d e s pite the patient
s re pe ate d e arne s t c
ries for he lp,
inclu d ings e ve ral ins tanc
e s whe re in he was e s s e ntially s tating I think I have c
anc
e r, his
s ym ptom s we re bru s he d offby the d oc
toru ntilthe re pe ate d pre s e ntations ofthis d yingm an c
ou ld
no longe rbe ignore d .
T he d e aths u m m ary was d one by none othe rthan the d oc
torre s pons ible forthis patient
sc
are (or
lac
k the re of). Ifone re ad s be twe e n the line s , the laps e s in c
are are hinte d at, bu t not re c
ognize d as
su c
h by the au thor. T he re is no ac
knowle d gm e nt that this patient
s d e ath was has te ne d by the
d oc
tor
s failu re to obtain the appropriate work-u pin atim e ly m anne r.
Patient #2
T his was a56-ye ar-old m an who was ad m itte d to ID O C on 10/12/11, trans fe rre d to H C C on
11/9/11 and d ied of non-H od gkin
s lym phom a on 9/9/13. H e had e le vate d live r e nz ym e s on
re c
e ption labs , bu t the s e we re not worke d u p. H e had no known c
hronicd ise as e s and s o was not
followe d in the c
hronicc
are program .
H e was s e e n e pisod ic
ally u ntil1/29/13, whe n he pre s e nte d to s ic
kc
allwithle ft-s id e d abd om inal
pain and was fou nd to have m arke d e nlarge m e nt ofhis s ple e n. T he d oc
tord id not ord erim aging,
only u rine and blood te s ts . H e told the patient to d rink m ore wate rand ord e re d naproxe n. T he C M P
s howe d am arke d ly e le vate d biliru bin at 7.7and m ild ly e le vate d A ST at 90. T his labwas s igne d
offby the d oc
torbu t not ac
te d u pon and the re was no follow-u pofthis.
T he patient pre s e nte d again on 5/7 withongoingle ft-s id e d abd om inalpain withd e e p bre athing
and lyingd own. H e was re fe rre d to M D SC the ne xt d ay and was s e e n by the nu rs e prac
titione r,
who took athorou ghhistory and note d le ft abd om inalte nd e rne s s and re fe rre d pain from right s ide d
palpation. She d e s c
ribe d the abd om e n as firm . She ord ere d abd om inalfilm s and an e valu ation by
the M e d ic
alD ire c
tor.
T he film s we re take n on 5/8and re ad 5/10as , Soft tiss u e d e ns ity m as s note d in the le ft abd om e n
m ay be re late d to m arke d s ple nom e galy. T he re is als o pos s ible he patom e galy...A C T orU S was
s u gge s te d . T he nu rs e prac
titione r s igne d the re port on 5/13 and note d that the M e d ic
alD ire c
tor
wou ld be followingu pwiththe patient the ne xt d ay.
M ay 2014
H illC orrec ti
onalC enter
P age 35
T he d oc
tors aw the patient the ne xt d ay, again noted te nd e rs ple nom e galy and s tate d that he wou ld
d isc
u s s the c
as e in c
olle gialre view and follow u pwiththe patient on 5/20.
O n 5/16, his blood work s howe d e le vate d live re nz ym e s and biliru bin, and alow plate le t c
ou nt.
O n 5/20, the patient s aw the M e d ic
alD ire c
tor, who again note d te nd e rhe patos ple nom e galy and
again note d he wou ld d isc
u s s the c
as e in c
olle gialre view. H e d isc
u s s e d the c
as e the ne xt d ay and
U S was approve d . It was d one on 5/30 and faxe d to the ins titu tion on 6/5. It s howe d m arke d
s ple nom e galy and C T was s u gge s te d forbe tte rd etail. Labs we re obtaine d , inc
lu d ingahe patitis C
te st whic
hwas pos itive . T he patient was re fe rre d to D r. P au lforhe patitis C c
linic
.
T he patient s aw the nu rs e prac
titione r on 5/24 to re view the labre s u lts . H e re porte d m u c
hle ft
s id e d abd om inalpainand ofc
ou rs e s tillhad firm e nlarge m e nt from m id line ...e xte nd ingto le ft
lowe r qu ad rant, te nd e r to palpation. She as ke d the M e d ic
alD ire c
tor abou t pain c
ontroland he
told he rto pre s c
ribe T yle nol, no narc
otic
s.
O n 6/6, he was s e e n in he patitis C c
linicby the nu rs e prac
titione r, who d oc
u m e nte d that he was in
c
ons tant pain and the m as s in his abd om e n was e nlarging. She s poke withthe M e d ic
alD ire c
tor
again and re fe rre d the patient bac
k to him onc
e the U S re port retu rns .
O n 6/12, the patient was d isc
u s s e d in c
olle gialre view again forre fe rralto D r. P au l.
O n 6/20, the patient s aw the d oc
tor, who d oc
u m e nte d that the patient s tate d , D oc
, I am m u ch
be tte r. M y pain is be tte r, m y he althis ge ttingbe tter...A gain, his m arke d s ple nom e galy is note d .
T he plan is that he is awaitingac
allfrom D r. P au lorD r. H aye s .
T he patient was not s e e n again u ntil two m onths late r on 8/27, whe n the nu rs e s aw him for
abd om inalpain, rate d 8/10withd ys pne aon e xe rtion, noc
tu rnalc
ou ghand e pistaxis. T he patient
was hypoxic
, u nable to s tand and his abd om e n was obviou s ly d iste nd e d . She pu t him on 4lite rs of
oxyge n and re fe rre d the patient to the d oc
torwho saw him that d ay, ad m itte d him to the infirm ary
and plac
e d him on antibiotic
s. A c
he s t x-ray s howe d right m id d le lobe and le ft lowe r lobe
c
ons olid ations . H is oxyge n re qu ire m e nts inc
re as e d u ntil he was on 10 lite rs by non-re bre athe r
m as k and s attingin the u ppe r80s . H e is c
le arly not ge ttingbe tte r.
Finally on 8/31, the R N in the infirm ary c
le arly has s om e c
onc
e rns abou t the patient. She c
alle d
the d oc
torwho ad vise d that the oxyge n be d e c
re as e d . She the n c
alle d the H C U A who ad vise d he r
to c
all the W e xford M e d ic
al D ire c
tor, who the n c
ontac
te d the Fac
ility M e d ic
al D ire c
tor. T he
Fac
ility M e d ic
alD ire c
torthe n c
alle d and ord e re d the oxyge n to be inc
re as e d bac
k to 10lite rs nonre bre athe rand to s e nd the patient ou t ifhis oxyge n s at we nt be low 85% , whic
hitd id that afte rnoon.
H e was trans fe rre d to C ottage H os pital, whe re he was ad m itte d to the IC U in c
ritic
alc
ond ition and
was fou nd to have non-H od gkin
s lym phom awithwide s pre ad ad e nopathy. H is c
ond ition rapid ly
d e te riorate d u ntilhe d ied le s s than two we e ks late r.
M ay 2014
H illC orrec ti
onalC enter
P age 36
T he d e ath s u m m ary was onc

e again writte n by the Fac
ility M e d ic
alD ire c
tor who c
om ple te ly
glos s e d ove rthe s ignific
anc
e ofthe e nlarge d s ple e n and foc
u s e d m ainly on the te rm inale ve nts in
the infirm ary, and the s e are d ownplaye d in c
om parison to how the c
hart re ad s .
Opinion:T he laps e s in c
are in this c
as e are m u ltiple and d istu rbing. T his patient pre s e nte d with
m as s ive s ple nom e galy bac
k in Janu ary 2013. W hile live r d ise as e c
an c
au s e e nlarge m e nt ofthe
s ple e n, the re are only afe w c
ond itions that c
au s e this d e gre e of e nlarge m e nt, with m alignancy
be ingthe m os t c
om m on c
au s e . It took fou r m onths to obtain the firs t appropriate im agingte s t
(u ltras ou nd ). W he n that te s t s u gge s te d the ne e d for m ore d e taile d im agingby C T s c
an, that
re c
om m e nd ation was ignore d d e s pite inc
re as ing c
linic
al e vid e nc
e of a s e riou s u nd e rlying
c
ond ition. A s in the pre viou s c
as e , the re is am arke d d isc
re panc
y in the d e s c
riptions ofthe patient
s
c
ond ition be twe e n the nu rs e prac
titione rand the d oc
tor, withthe latte rprovide rd ownplayingthe
s itu ation to an u nre alisticd e gre e . E ve n whe n the patient pre s e nte d as c
linic
ally u ns table with
s e ve re hypoxia, the d oc
tord id not s e nd the patient ou t u ntilhe was pre s s e d to d o s o. In ou ropinion,
this c
an only be c
ons tru e d as d e libe rate ind iffe re nc
e.

W e re viewe d the C Q I m inu te s with the le ad e rs hip te am and c
om m e nd e d the m on the ir d ata
c
olle c
tion, whic
hs e e m s to be qu ite c
om pre he ns ive . H owe ve r, the re is no d oc
u m e nte d analys is of
the d atanord o we find any d oc
u m e nte d e fforts whe re d atahave be e n u s e d to im prove the qu ality
of s e rvic
e s . T his was d isc
u s s e d in s om e d e tailwiththe le ad e rs hip te am . It appe are d that s om e
things are m onitore d e ve ry m onthe ve n thou ghthe pe rform anc
e is virtu ally e ve ry m onthat 100%.
W e d isc
u s s e d the ne e d to u s e the C Q I program to find proble m s s u c
has the one s we had be e n able
to ide ntify d u ringou rvisit.
M ay 2014
H illC orrec ti
onalC enter
P age 37
Recommendations
1. T he M e d ic
al D ire c
tor perform anc
e , both ad m inistrative ly and c
linic
ally, m u s t be
s ignific
antly im prove d .
1. U tilize the qu ality im prove m e nt program to im prove follow u p afte r ide ntific
ation of
proble m s .
Nursing Sick Call:
1. T rans ition to as ic
kc
allproc
ess c
ond u c
te d only by R e giste re d N u rs e s .
2. M e d ic
als taff, rathe rthan s e c
u rity s taff, s hou ld be c
olle c
tingthe c
om ple te d s ic
kc
allre qu e s t
form s .
c
ontrol, withpoorly c
ontrolle d
patients s e e n m ore fre qu e ntly. In this way, longpe riod s of e xpos u re to the d e le te riou s
e ffe c
ts ofs u boptim ald ise as e c
ontrol(highblood pre s s u re , highblood glu c
os e , etc
.)c
an be
m inim ize d .
2. T he c
hronicc
are nu rs e s hou ld re view the patient
s m e d ic
ation c
om plianc
e viathe M A R s ,
and have the m os t re c
e nt m onths worthavailable forthe c
linic
ians re view at the tim e of
the c
hronicc
are visits .
3. T he re s hou ld be am e c
hanism in plac
e by whic
h the pre s c
ribingprovide r is notified of
patients m e d ic
ation nonc
om plianc
e in atim e ly m anne r.
4. P atients with H IV infe c
tion s hou ld be followe d by one of the fac
ility provid e rs for
m onitoringofm e d ic
ation c
om plianc
e and s id e e ffe c
ts and s o that the y are at le as t fam iliar
withthis high-risk popu lation.
1. T he qu ality im prove m e nt program s hou ld m onitorthe pre s e nc
e d oc
u m e nts
and follow u p withthe prim ary c
are provid e r. T hos e follow-u p e nc
ou nte rs m u s t inc
lu d e
d oc
u s s ion withthe patient re gard ingthe find ings and plan.
1. N u rs e s m u s t be re traine d re gard ingthe irprofe s s ionalobligations whe n patients pre s e nt with
c
he s t pain.
M ay 2014
H illC orrec ti
onalC enter
P age 38
1. T he qu ality im prove m e nt program m u s t m onitorthe pre s e nc

e
d oc
u m e nts , inc
lu d ingatim e ly follow-u pe nc
ou nte rwiththe prim ary c
are c
linic
ian in
whic
hthe re is ad isc
2. T he qu ality im prove m e nt program m u s t m onitorfollow u pby the prim ary c
are c
linic
ian
withthe patient afte rthe c
olle gialre view re s u lts in ac
hange to the plan.
Infection Control:
1. Infirm ary be d d ingand line ns are lau nd e re d in the he althc
are u nit, and the te s te d wate r
te m pe ratu re is not hot e nou ghto ins u re c
om ple te s anitizing. Ins u re infirm ary be d d ingand
line ns are appropriate ly s anitize d .
2. Infirm ary m attre s s e s and othe ru phols te re d e qu ipm e nt we re obs e rve d to have te ars and
c
rac
ks in the ou te rim pe rviou s c
oatingwhic
hd oe s not allow forprope rs anitizing. T he s e
ite m s s hou ld be re paire d orre plac
ed .
CQI
ontinu ou s qu ality im prove m e nt program m u s t be retraine d
re gard ingqu ality im prove m e nt philos ophy and m e thod ology, alongwiths tu d y d e s ign
and d atac
olle c
tion.
lu d e how to stu d y ou tliers in ord e rto d e ve loptargete d
im prove m e nt strate gies .
M ay 2014
H illC orrec ti
onalC enter
P age 39

Patient Number
Name
Inmate ID
[redacted]
[redacted]
P atient #1
P atient #2
Unscheduled Offsite Services/Emergencies:
Patient Number
Name
Inmate ID
[redacted]
[redacted]
P atient #1
P atient #2
Patient Number
Name
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
Chronic Disease:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
P atient #11
P atient #12
P atient #13
P atient #14
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Mortality Review:
Patient Number
P atient #1
M ay 2014
Name
[redacte
H illC orrec ti
onalC enter
Inmate ID
[redact
P age 40
P atient #2
M ay 2014
[redacted]
H illC orrec ti
onalC enter
[redacted]
P age 41
Menard Correctional Center

(MCC) Report
June 17-20, 2014

Ron Shansky, MD
Karen Saylor, MD
Larry Hewitt, RN
Karl Meyer, DDS
Contents
Overview....................................................................................................................................3
Findings .....................................................................................................................................6
C linicSpac
e and Sanitation .....................................................................................................7
R ec
e ption P roc
e s s ing...............................................................................................................8
M e d ic
alR e c
ord s ......................................................................................................................9
N u rs ingSic
k C all...................................................................................................................10
P harm ac
y/M e d ic
Laboratory .............................................................................................................................22
U rge nt/E m e rge nt C are /U ns c
e s ............................................................23
Sc
e d u re s )...................................................24
Infirm ary C are .......................................................................................................................27
Infe c
tion C ontrol...................................................................................................................28
D e ntalP rogram ......................................................................................................................31
Ju ne 2014
M enard C orrec ti
onalC enter
P age 2
Overview
O n Ju ne 17-20, 2014, we visite d the M e nard C orrec
tionalC e nte r(M C C )in M e nard , Illinois. T his
was ou rfirs t s ite visit to M C C and this re port d e s c
om m e nd ations . D u ring
this visit, we :
al
als e rvic
e s are a
are s taff
u m e nts
W e thank W ard e n K im B u tle rand he rs taffforthe iras s istanc

e and c
oope ration in c
ond u c
tingthe
re view.
Executive Summary
M e nard C orre c
tionalC e nte r is alarge , old fac
ility with originalc
ons tru c
tion s tartingin 1870.
D u ringthe ins pe c
tion, the popu lation was re porte d at 3750. T he fac
ility als o s e rve s as the Sou the rn
Illinois R e c
ation c
e nte r and m onthly re c
e ive s approxim ate ly 100 ne wly
c
om m itte d ind ivid u als to the D e partm e nt ofC orrec
tions .
T he H e alth C are U nit, athre e -s tory bu ild ing, was ne wly c
ons tru c
te d and ope ne d in 1980 and
appe ars to have had no re novation s inc
e ope ning.
M e nard is a m axim u m -s e c
u rity prison that als o has a m e d iu m -s e c
u rity u nit ou ts ide the m ain
c
om ple x as we llas as m allm inim u m popu lation that s e rve s m ainly as the c
ad re ofworke rs . T he
c
u rre nt popu lation is approxim ate ly 3233inm ate s , with595(18% )ove rthe age of50. T he ave rage
age is 39 ye ars . O ve r 80% ofthe popu lation is s e rvingm ore than 10 ye ars . T he ins titu tion is a
re c
e ption c
e nte rwhic
hre c
e ive s approxim ate ly 100inm ate s pe rm onth. It has a26-be d infirm ary
and ou tpatient m e ntalhe althm iss ion.
T he re is ane w H e althC are U nit A d m inistrator(H C U A );howe ve r, s he has worke d at the fac
ility
anu m be rofye ars , ad vanc
ingfrom s taffR N to s u pe rvisingR N to D ire c
torofN u rs ing(D O N )to
H C U A . A s are s u lt of this m os t re c
e nt prom otion, the D O N pos ition and one s u pe rvisingR N
pos ition are vac
ant. T he re is afu ll-tim e s u rgic
ally traine d M e d ic
alD ire c
tor.
als e rvic
e s are provid e d throu ghac
ontrac
tu alagre e m e nt withthe Illinois
tions and W e xford H e althSou rc
e s loc
ate d in P itts bu rgh, P A . O ve rs ight and
m onitoring of the m e d ic
al program is provide d by the s tate -e m ploye d H e alth C are U nit
A d m inistrator (H C U A ). H e alth c
are s taff is on-d u ty 24 hou rs ad ay, s e ve n d ays awe e k, and a
phys ic
ian is always available on-c
all.
T he c
e llhou s e s ic
kc
allroom s are ge ne rally inad e qu ate and u nac
c
e ptable for u s e as an are ato
c
ond u c
t private s ic
kc
alle xam inations and as s e s s m e nts . W ork has be gu n in the E ast c
e llhou s e to
Ju ne 2014
M enard C orrec ti
onalC enter
P age 3
provide ane w s ic
kc
allare a. C om ple tion ofthis work, as we llas re novatingallc
e llhou s e s ic
kc
all
are as s hou ld be apriority. A d d itionally, s om e ofthe are as we re inad e qu ate ly e qu ippe d .
Sic
kc
allis c
ond u c
te d s e ve n d ays awe e k, and m e d ic
ation is ad m iniste re d s e ve n d ays awe e k as
ord ere d by the phys ician. T he nu rs ings ic
kc
allproc
e s s is proble m atic
, in that nu rs ings taffas s igne d
are workingbe yond the ir lic
e ns e d s c
ope ofprac
tic
e . A s are s u lt, patient ac
c
e s s and appropriate
as s e s s m e nt is d e laye d . A s ic
kc
allproc
e d u re whic
h is c
ond u c
te d by lic
e ns e d re giste re d nu rs ing
s taffs hou ld be im m e d iate ly im ple m e nte d . To d o so willre s u lt in are c
onfigu ringofc
u rre nt staff
and m ay re s u lt in the ne e d forad d itionalre giste re d nu rs ingpos itions .
T he re we re five fu ll-tim e c
linic
ians at the tim e of ou r visit;thre e phys ic
ians and two nu rs e
prac
titione rs . N one ofthe phys ic
ians is traine d in aprim ary c
are field . T he M e d ic
alD ire c
toris a
ge ne rals u rge on who has no priorc
orre c
tionalhe althc
are e xpe rienc
e and is als o ne w to the fac
ility.
T he two ad d itionalphys ic
ians we re traine d in ophthalm ology and ge ne rals u rge ry, re s pe c
tive ly.
T he re is the re fore avac
u u m of c
linic
al le ad e rs hip am ongthe phys ic
ians , whic
h is partic
u larly
proble m aticfor the nu rs e prac
titione rs , one ofwhom is re lative ly ne w and who the re fore le ans
he avily u pon the othe rnu rs e prac
titione r. T his arrange m e nt c
re ate s liability forallinvolve d and is
ac
ons e qu e nc
e ofthe ve nd or
s willingne s s to hire u nd e rqu alified c
linic
ians and u nwillingne s s to
provide appropriate c
linic
alove rs ight the re afte r.
A s e vid e nc
e ofthis liability, we ide ntified ac
as e ([redacted])in whic
hfailu re to ide ntify and
appropriate ly m anage ac
om m on prim ary c
are c
ond ition (d iabe ticfoot u lc
e r)le ad to ac
tu alharm
to the patient (am pu tation). T his patient, atype 1d iabe tic
, the n had his ins u lin d isc
ontinu e d by one
ofthe d oc
tors . T his re fle c
ts alac
k ofbas icu nd e rs tand ingofthis d ise as e proc
ess.
In te rm s ofothe rs ou rc
e s ofm e d ic
alinform ation, only the M e d ic
alD ire c
torhas ac
om pu te rand
inte rne t ac
c
e s s , albe it in his offic
e and not at the point ofc
are . T he othe r provide rs c
an u s e his
c
om pu te rbu t this is not e ffic
ient orprac
tic
alon ad ay-to-d ay bas is. A s are s u lt, the provide rs re ly
he avily u pon e ac
hothe rform e d ic
alinform ation and c
ons u ltations . T his is worrisom e c
ons id e ring
the pau c
ity ofprim ary c
are trainingam ongthe d oc
tors.
N e e d le s s to s ay, this fac
ility wou ld be ne fit gre atly from , and in ou ropinion re qu ire s , one orm ore
prim ary c
ians .
Infe c
tion c
ontroliss u e s ne e d to be ad d re s s e d , in that he althc
are u nit inm ate /porters have not be e n
traine d in blood -borne pathoge ns , infe c
tiou s and c
om m u nic
able d ise as e s , bod ily flu id c
le an-u p,
the prope r c
le aning and s anitation of infirm ary room s , be d s , fu rnitu re and line ns and
c
onfid e ntiality of m e d ic
alinform ation. T orn and ragge d be d d ingand line ns s hou ld be re plac
ed
and an ad e qu ate s u pply of c
le an line ns m aintaine d in inve ntory. Infirm ary line ns are not be ing
appropriate ly s anitize d d u e to ins u ffic
ient hot waterte m pe ratu re .
T he ou ts ide plas ticbarrier on fu rnitu re , e xam ination table s and infirm ary be d m attre s s e s in the
he althc
are u nit we re c
rac
ke d and torn, whic
hpre ve nts s anitizingbe twe e n patients . E xam ination
table s in the c
e llhou s e s ic
kc
allare as als o had c
rac
ke d ortorn plas ticbarriers . T he s e ite m s ne e d
to be im m e d iate ly re paire d orre plac
e d . A d d itionally, in boththe c
e llhou s e s ic
kc
allare as and
Ju ne 2014
M enard C orrec ti
onalC enter
P age 4
the he althc
are u nit e xam ination room s the re was no u s e ofapape rbarrieron e xam ination table s
be twe e n patients .
T he re is a26-be d infirm ary on the third floorofthe H e althC are U nit. T he u nit is s taffe d 24hou rs
ad ay, s e ve n d ays awe e k by aR N , and the M e d ic
alD ire c
torprovide s the ove rs ight forthe m e d ic
al
m anage m e nt ofthe u nit.
In the infirm ary, patients are pad loc
ke d in the ir room s and life /safe ty iss u e s are a c
onc
e rn.
A d d itionally, the re is no nu rs e c
alls ys te m .
T he re are no visu alor au d ible alarm s ind ic
atinglos s of ne gative air pre s s u re for the infirm ary
re s piratory isolation room s . Gau ge s ind ic
ating c
u rre nt pre s s u re are available . T he re is no
d oc
u m e ntation orm onitoringofairpre s s u re whe n apatient is in the room forre s piratory isolation
pu rpos e s .
A lthou ghthe re c
e ption proc
e s s is u s u ally c
om ple te , that is, allthe re qu ire d ite m s are pe rform e d ,
whe n abnorm alfind ings are ide ntified , it is qu ite c
om m on forthe m not to be ad e qu ate ly ad d re s s e d .
T he proc
e s s ofthe c
linic
ians pe rform ingthe history and phys ic
aland ju s t listinglaband history
re viewe d withou t c
om m e ntingon the re s u lts c
ontribu te s to the inad e qu ac
y ofthe intake proc
ess.
In ad d ition, patients withc
hronicd ise as e s s u c
has as thm awho are s e e n e arly on in ac
hronicc
are
c
linicwill not and have not re c
e ive d appropriate c
are whe n the c
linic
ians d o not c
orre c
tly
u nd e rs tand the d e finitions ofd ise as e c
ontrol.
Forpatients withs c
e s , in ge ne ralthe proc
e s s oc
c
u rs tim e ly;howe ve r, the re
are e xc
e ptions and thos e e xc
e ptions c
an take m onths . T he re s hou ld be as hort c
irc
u it for the
M e d ic
alD ire c
tor to get to the State M e d ic
alD ire c
tor in ord e r to ac
c
om plish the s e rvic
e m ore
tim e ly. In ad d ition, whe n patients are s e nt fors c
e s , ac
linic
ally traine d s taff
pe rs on s hou ld ins u re that the re qu ire d d oc
u m e nts are available tim e ly s o that the re c
an be a
prod u c
tive follow-u p visit be twe e n the prim ary c
are c
linician and the patient d u ringwhic
h the
find ings and plan are d isc
u s s e d and this is d oc
u m e nte d . W e fou nd visits oc
c
u rringtim e ly on a
follow-u pbas is, bu t the iss u e forwhic
hthe patient was s e nt offs ite was not ne c
e s s arily d isc
u ssed ;
in fac
t, ofte n tim e s the re qu ire d re ports we re not available .
W ithre gard to u ns c
e s , ac
linic
ally traine d pe rs on m u s t ins u re that the re le vant
d oc
u m e nts from the hos pital, s u c
h as d isc
harge s u m m aries , e m e rge nc
y room re ports , ope rative
proc
e d u re s , c
athe te rization re ports, etc
., are available tim e ly within afe w d ays afte r retu rn from
the hos pitals o that the appropriate follow u p c
an be pe rform e d . A gain, the c
linic
ian m u s t m e e t
withthe patient and d isc
u s s boththe find ings and plan.
T he qu ality im prove m e nt program , althou ghre fle c
tive oftre m e nd ou s e ffort to c
om ply withthe
re qu ire m e nts ofthe polic
y, are not c
onne c
te d to im provingthe qu ality ofs e rvic
e . T he re fore , the
polic
y as we llas the trainingofs taffm u s t be re e xam ine d and re d one . A ls o, the m e d ic
alre c
ord s
d ire c
torhas re c
e ntly be e n as s igne d to he ad u pthe qu ality im prove m e nt program bu t has not be e n
provide d ad e qu ate trainingin ord e rto as s u m e that role . T his m u s t be apre re qu isite foranybod y
who is as s igne d that re s pons ibility.
Ju ne 2014
M enard C orrec ti
onalC enter
P age 5
Findings
T he M e d ic
alD ire c
tor pos ition is fille d by ac
linic
ian traine d as age ne rals u rge on. In fac
t, the re
are no prim ary c
are traine d c
linic
ians to provide ove rs ight and s u pe rvision to the m id le ve lprim ary
c
are c
linic
ians . T he he althc
are u nit ad m inistratorappe ars qu ite c
apable bu t m u s t als o fu nc
tion as
the D ire c
torofN u rs ingbe c
au s e that pos ition is vac
ant. T his gre atly im pac
ts the ad e qu ac
y ofthe
ove rs ight of nu rs ing profe s s ional pe rform anc
e . T he M e d ic
al R e c
ord s D ire c
tor was re c
e ntly
as s igne d the jobofQ u ality Im prove m e nt C oord inator. H owe ve r, s he has be e n provide d no bas ic
trainingfor he r c
oord inator re s pons ibilities . O u r re view re fle c
ts s ignific
ant proble m s bas e d on
the s e le ad e rs hipiss u e s .
T he re is ale ad e rs hip te am in plac
e withafu ll-tim e , s u rgic
ally traine d M e d ic
alD ire c
tor, H e alth
C are U nit A d m inistrator (H C U A ), M e d ic
al R e c
ord s D ire c
tor and two s u pe rvisingre giste re d
nu rs e s . T he H C U A is ne w to the pos ition bu t has worke d at the fac
ility fors e ve ralye ars , hold ing
pos itions as as taffR N , s u pe rvisingR N and , m os t re c
e ntly, the D ire c
torofN u rs ing. A s are s u lt,
the D ire c
torofN u rs ingpos ition is now vac
ant, and one s u pe rvisingR N pos ition is vac
ant. H iring
aD ire c
torofN u rs ingand s u pe rvisingnu rs e as s oon as pos s ible is ne e d e d in ord e rto allow the ne w
H C U A the opportu nity to foc
u s on d ire c
tingahe althc
are program rathe rthan havingto foc
u s on
d ay-to-d ay ope rational, i.e ., s taffingand pe rs onne l, iss u e s . Five ofthe s ix bu d ge te d c
ontrac
t RN
pos itions are fille d , and all17ofthe s tate R N pos itions are fille d . T we nty-one ofthe 23bu d ge te d
C orre c
tional M e d ic
al T e c
hnic
ian/Lic
e ns e d P rac
tic
al N u rs e pos itions are fille d . O u t of 101.0
approve d FT E s , the re are only 9.0FT E pos itions vac
ant.
A s re porte d by the H e alth C are U nit A d m inistrator (H C U A ), the re is m inim al nu rs ings taff
tu rnove r.
A d d itionally, the program wou ld gre atly be ne fit ifthe M e d ic
alD ire c
torpos ition we re to be fille d
by aprim ary c
ian.
A re view of m e d ic
als taff c
e ns u re ind ic
ate s taff that has be e n appropriate ly
traine d , are c
u rre ntly lic
tive s c
ope s ofprac
tic
e pu rs u ant to
writte n jobd e s c
riptions .
Position
M e d ic
alD ire c
tor
StaffP hys ic
ian
N u rs e P rac
titione r
D ire c
torofN u rs ing
Su pe rvisingN u rs e
M e d ic
alR e c
ord s D ire c
tor
Ju ne 2014
Current FTE
1.0
2.0
2.0
1.0
1.0
3.0
1.0
M enard C orrec ti
onalC enter
Filled
1.0
2.0
2.0
1.0
2.0
1.0
Vacant
1.0
1.0
State/Cont.
C ontrac
t
C ontrac
t
C ontrac
t
State
State
State
C ontrac
t
P age 6
Position
M e d ic
alR e c
ord s A s s istant
C orre c
tions N u rs e I (R N )
C orre c
tions N u rs e II (R N )
C M T -Lic
e ns e d P rac
tic
alN u rs e
O ffic
e A s s istant/A s s oc
iate
StaffA s s istant
M e ntalH e althA d m inistrator
M e ntalH e althStaff
M e ntalH e althStaff
P harm ac
y Tec
hnic
ian
P hle botom ist
P hle botom ist
C hiefD e ntist
D e ntist
D e ntist
D e ntalH ygienist
O ptom e try
R ad iology T e c
hnic
ian
Total
Current FTE
7.0
6.0
3.0
14.0
23.0
6.0
3.0
1.0
7.0
4.0
2.0
1.0
1.0
1.0
1.0
1.0
5.0
1.0
1.0
1.0
1.0
101.0
Filled
5.0
5.0
3.0
14.0
21.0
6.0
3.0
0.0
7.0
3.0
2.0
1.0
1.0
1.0
1.0
1.0
5.0
1.0
1.0
1.0
1.0
92.0
Vacant
2.0
1.0
2.0
1.0
1.0
State/Cont.
State
C ontrac
t
State
State
State
State
C ontrac
t
State
C ontrac
t
State
C ontrac
t
State
C ontrac
t
C ontrac
t
C ontrac
t
State
C ontrac
t
State
State
C ontrac
t
C ontrac
t
9.0

T he M e nard C orre c
tionalC e nte rhe althc
are u nit ope ne d in 1980as ne w c
ons tru c
tion. Sinc
e that
tim e , the fac
ility has be e n ge ne rally we llm aintaine d bu t is c
e rtainly s howingage and appe ars to
have had no m ajorre novation s inc
e ope ning. T he he althc
are u nit (H C U )is athre e -s tory bu ild ing
withthre e inm ate hold ingare as , one large and two s m all, ou tpatient m e d ic
als e rvic
e s withthre e
e xam ination room s , afou r-c
hair d e ntalc
linicand firs t aid on the firs t floor, m u ltiple offic
es,
pharm ac
y/m e d ic
ation s torage, c
e ntral s u pply and rad iology on the s e c
ond floor and a26-be d
infirm ary on the third floor.
Spac
e has be e n e s tablishe d in e ac
hc
e llhou s e , Sou th(u ppe rand lowe r), N orth, N orth2, E ast and
W e s t, to c
ond u c
t e ithe rnu rs e orphys ic
ian s ic
kc
all. T he ide ntified are as we re form e rinm ate c
e lls
and ne ve rd e s igne d as ac
linic
ale nvironm e nt. C u rre ntly, the are as provide little to no privac
y, and
allofthe are as are not appropriate ly e qu ippe d . R e novations have be gu n in the E as t C e llH ou s e to
provide foran appropriate ly e qu ippe d , c
le an, private c
linic
als e tting. R e novation ofallthe are as
in e ac
hhou s ingu nit s hou ld be m ad e apriority.
A re lative ly ne w R e c
ation U nit inc
lu d e s as m allbu t appropriate ly e qu ippe d
c
linic
alare awhic
hprovid e s forprivac
y d u ringe xam inations orproc
e d u re s .
Ju ne 2014
M enard C orrec ti
onalC enter
P age 7
In the H C U e xam ination room s , the re was no u s e ofapape rbarrieron e xam ination table s which
c
ou ld be c
hange d be twe e n patients and the re was no c
le aningofthe table s u rfac
e be twe e n patients .
Sim ilarly, in the c
e llhou s e s ic
kc
allroom s , the re was no u s e ofpape ron the e xam ination table s
and no c
le aningofthe table s be twe e n patients . A d d itionally, the Sou thLowe rc
e llhou s e s ic
kc
all
room had no s ink forhand was hing. T he re is an as s igne d Infe c
tion C ontrolR N who has be e n in
the pos ition thre e ye ars and c
ond u c
ts d oc
u m e nte d m onthly s afe ty and s anitation ins pe c
tions
throu ghou t the fac
ility.
ord s ofpatients who had e nte re d the fac
ility s inc
e Fe bru ary of2014, that is in
the pas t fou r or five m onths . O fthe 12 re c
ord s re viewe d , thre e had c
om ple te ly ne gative intake
e xam s . A lm os t allre c
ord s c
ontain the re qu ire d e le m e nts from the intake proc
e s s , whic
his anu rs e
sc
re e n, ahistory and phys ic
al, tu be rc
u los is s c
re e ningas we llas ne c
e s s ary labre ports . H owe ve r,
ofthe nine re c
ord s in whic
hthe re we re one orm ore abnorm alfind ings, the re we re proble m s with
the qu ality ofthe proc
e s s , and as are s u lt, e le m e nts whic
hs hou ld have be e n pe rform e d in ord e rto
ins u re follow u p we re not ad d re s s e d . W hat follows is alist of e xam ple s of proble m s with the
re c
e ption proc
ess.
Patient #1
T his inm ate arrive d on 5/29/14. H e is a49-ye ar-old withahistory ofs m oking, we aringe ye glas s e s
and ahistory of m igraine he ad ac
he s tre ate d with Im itre x m e d ic
ation. H is tu be rc
u los is s kin te s t
was norm alas we re his vitals igns . T he re is no d oc
u m e ntation that we c
ou ld find ofan ord e rfor
his m igraine m e d ic
ation and the re was no m e ntion in the history and phys ic
al. H is laboratory te s ts
we re liste d as re viewe d bu t the re is no m e ntion ofthe re s u lts .
Patient #2
T his inm ate arrive d on 5/21/14. H e is a52-ye ar-old who re fu s e d an H IV te s t. H e has ahistory of
s m oking. H e had ane gative T B s kin te s t and his blood pre s s u re was 140/88. H e d oe s have ahistory
ofkne e and he ad inju ries . H is lipid s tu d ies we re qu ite e le vate d and ye t this was not ide ntified , nor
was the re any re fe rralto ad d re s s this proble m .
Patient #3
T his inm ate arrive d on 5/9/14. H e is a54-ye ar-old withahistory ofas thm aand his m os t re c
e nt
attac
k was one m onthago. H e als o has he patitis C , d iagnos e d aye ar ago. H is T B s kin te s t was
ne gative . H e has d ru nk alc
oholforthre e d e c
ad e s and has u s e d m ariju anaand c
oc
aine . H is phys ic
al
e xam was pe rform e d on the s ixthd ay afte r intake . H e d id not have are c
tale xam be c
au s e the re
was no s olu tion available . H e was re fe rre d forac
hronicc
are visit forbothas thm aand he patitis C ;
howe ve r, the as thm ac
linicvisit as s e s s e d him as be ingin good c
ontrolas an inte rm itte nt as thm atic
,
d e s pite the fac
t that he had are c
e nt attac
k and u s e d be taagonist inhale rs d aily. H is d e gre e of
c
ontrol was not good and he probably warrante d an inhale d s te roid. H is proble m was not
ad e qu ate ly ad d re s s e d .
Patient #4
T his patient arrive d on 5/2/14. H e is a54-ye ar-old with hype rte ns ion, s u bs tanc
e abu s e and an
e le vate d blood pre s s u re of162/100. H is T B s kin te s t was ne gative . T he nu rs e s hou ld have
Ju ne 2014
M enard C orrec ti
onalC enter
P age 8
re c
om m e nd e d d aily blood pre s s u re c
he c
ks in ord er to obtain m ore d atapoints , bu t this was not
d one . H e was s e e n one we ek laterforhis history and phys ic
al. H e was give n an antihype rte ns ive as
we llas m e d ic
ation fore le vate d lipids . H is s e xu ally trans m itte d d ise as e te sts we re ne gative .
Patient #5
T his patient arrive d in Janu ary 2014. H e is a47-ye ar-old whos e nu rs ings c
ree n was pe rform e d on
1/3/14. H e arrive d with ahistory of ale ft e ye proble m , s e xu ally trans m itted d ise as e s , agu ns hot
wou nd to his right le g, e ye su rgery as ac
hild and apriorbu lle t wou nd to the c
he st. H is blood pre s s u re
was e le vated at 148/86. H is T B s kin te st was negative . T here is no re c
om m e nd ation for blood
pre s su re m onitoring. O nc
e again, there is ad e s c
ription that his history and laboratory stu d ies were
re viewe d bu t no c
om m e nt on the re s u lts. H e als o had ahistory oftrans fu s ions , bu t no d ate was
attac
he d and there fore there was no d eterm ination as to the risk forhe patitis C . H is blood lipids we re
e le vated and there has be e n no follow u pforthe s e abnorm alre su lts.
Patient #6
T his patient arrive d in M arc
h2014. H e is a47-ye ar-old withahistory ofs m okingand he aring
proble m s . H is blood pre s s u re was e le vate d and he had ahistory ofwrist pain. H e had right e ar
s u rge ry in 2006. T he re we re no lipid s tu d ies in his re c
ord and ye t the phys ic
ian wrote re viewe d
labs withno c
om m e nt.
Patient #7
T his patient arrive d on 5/15/14. H e is a74-ye ar-old whos e proble m list c
ontains ahistory of
d e tac
he d re tina, gou t, d ys lipid e m ia, hype rte ns ion and d iabe te s alongwithprostate c
anc
e r and a
prostate c
tom y. H is phys ic
ale xam was on 5/20/14 and ye t it lac
ks afu nd os c
opice xam . H e was
be ingtre ate d for the blood pre s s u re , the gou t and hype rlipid e m ia. H e was s e e n on 6/16/14. H is
blood te s ts inc
lu d e d an e le vate d c
re atinine , bu t the re is no m e ntion ofc
hronickid ne y d ise as e . E ve n
thou ghhe was be ingtre ate d forgou t, the re is no ord e rforau ricac
id le ve l. H is follow u pne e d s to
be m ore c
om pre he ns ive ly ad d re s s e d .
Patient #8
T his patient arrive d in Fe bru ary 2014. H e is a47-ye ar-old withahistory ofhe patitis C and apast
pos itive tu be rc
u los is te s t. T he form ind ic
ate s lab and history re viewe d . H e had an inte rview
re gard inghis priorpos itive te s t bu t s hou ld have had ac
he s t x-ray;the re was none available in the
c
hart. H e was re fe rre d forhe patitis C c
linicbu t he re fu s e d laboratory s tu d ies .
Patient #9
T his patient arrive d on 5/23/14. H e is a 55-ye ar-old with as thm a, C O P D and he is oxyge n
d e pe nd e nt. H is vitals we re norm al. H is intake proc
e s s ind ic
ate s history and labs re viewe d . H is
phys ic
ale xam was not pe rform e d u ntilalm os t two we e ks afte rhis s c
re e n. A lthou ghthe loc
ation
on the form for plac
e m e nt is blank, he appare ntly was plac
e d in the infirm ary, as he has be e n
re c
e ivingoxyge n.
Medical Records
C harts we re ke pt re as onably we llthinne d . P roble m lists we re bu ried u nd e r the ord er s he e ts and
we re c
lu tte re d withu nne c
e s s ary and re d u nd ant inform ation, s u c
has e ve ry c
hronicc
are c
linic
Ju ne 2014
M enard C orrec ti
onalC enter
P age 9
that had be e n c
om ple te d . In othe rc
as e s , c
ru c
ialm e d ic
alinform ation was m iss ingfrom the proble m
lists , s u c
has one c
as e ofapatient withahistory ofc
oronary arte ry d ise as e and s te nts . R are ly d id
the fac
ility re c
e ive vitalm e d ic
alre c
ord s from ou ts id e s ou rc
es su c
has e m e rge nc
y room re ports and
d isc
harge s u m m aries followinghos pitalizations . U ntil ve ry re c
e ntly, the re was a prac
tic
e of
d isc
ard ingthe s ic
kc
alls lips afte rloggingthe m into the logbook. T his prac
tic
e was in the proc
ess
ofbe ingm od ified s u c
hthat the s ic
kc
alls lips wou ld be ke pt as part ofthe he althre c
ord , as the y
s hou ld be .
Nursing Sick Call

T he fac
ility u s e s as c
he d u le d s ic
kc
allre qu e s t s lips tyle s ic
kc
alls ys te m forbothge ne ralpopu lation
and s e gre gation inm ate s . Sic
kc
allis c
ond u c
te d s e ve n d ays awe e k. R e qu e st s lips are available in
e ac
hc
e llhou s e . C om ple te d re qu e sts are plac
e d d ire c
tly into aloc
ke d m e d ic
ald rop-box loc
ate d in
e ac
hc
e llhou s e . M e d ic
als taff, e ithe raR N orLP N /C M T workingthe 7a.m . to 3p.m . s hift c
olle c
ts
the re qu e sts e ac
hd ay. W he n bac
k in the he althc
are u nit, the R N orLP N /C M T who c
olle c
te d the
re qu e sts re views e ac
h s lip for rou tine ve rs u s u rge nt he alth c
are ne e d s and d oc
u m e nts on e ac
h
ind ivid u alc
e llhou s e s ic
kc
alllogthe inm ate
s nam e , nu m be r, d ate, tim e , c
om plaint and d ate to be
e valu ate d . If the R N or LP N /C M T d ete rm ine s the re qu e st is of an u rge nt natu re, the inm ate is
im m e d iate ly e valu ate d by e ithe raR N orLP N . Ifthe R N orLP N /C M T d eterm ine s the re qu e st is of
arou tine natu re, the inm ate is s c
he d u le d fornu rs ings ic
kc
allwithin 48hou rs .E ac
hd ay, LP N /C M T s
as s igne d to e ac
hc
e llhou s e obtain the irc
e llhou s e s ic
kc
alllogforthe d ay and c
ond u c
t s ic
kc
allin
ad e s ignate d room in e ac
hc
e llhou s e . O nc
e the nu rs ings ic
kc
alle nc
ou nterhas oc
c
u rre d , the original
inm ate re qu e st s lip is d e s troye d and allthat re m ains is the d oc
u m e ntation on the s ic
kc
alllogand
in the patient s pe c
ificm e d ic
al re c
ord . D e partm e nt of C orre c
tions O ffic
es
approve d tre atm e nt protoc
ols are u s e d fore ac
hnu rs ings ic
kc
alle nc
ou nte r. T he protoc
ols are on a
pre -printe d form and provide apathway oftre atm e nt bas e d on inm ate provide d inform ation and
phys ic
al find ings. N u rs ings ic
kc
all c
ou ld be c
ond u c
te d by e ithe r aR e giste red N u rs e (R N ) or
Lic
e ns e d P rac
tic
al N u rs e (LP N ). P er ID O C polic
y, all nu rs ings taff are initially traine d by a
phys ic
ian on appropriate u s e ofthe tre atm e nt protoc
ols and retraine d annu ally. A d d itionally, e ac
h
fac
ility M e d ic
alD ire c
toris re qu ire d to m onthly re view two m e d ic
alre c
ord s pe rnu rs ingprovide r
for the appropriate ne s s of u s e of the protoc
ols . The re s u lts of the M e d ic
alD ire c
tor re view are
d isc
u s s e d with e ac
h ind ivid u alnu rs ingprovide r and inc
lu d e d as apart of the m onthly Q u ality
Im prove m e nt m e e ting.
T he room s c
u rre ntly in u s e in e ac
hc
e ll hou s e for s ic
kc
all are le s s than id e al and c
annot be
c
ons id e re d as c
linic
al s e ttings. Ins pe c
tion of e ac
h of the are as ind ic
ate d noisy, c
lu tte re d and
ins u ffic
iently e qu ippe d room s withno privac
y. N o e xam ination table s we re available in the Sou thU ppe rand Lowe rs ic
kc
allroom s and the N orth2LP N /C M T room . A d d itionally, the Sou th-Lowe r
room had no s c
ale , e ye c
hart ors ink forwas hinghand s . In the N orth2s ic
kc
allare a, the re are no
ac
c
om m od ations forprivac
y and , as are s u lt, proc
e d u re s ore xam inations re qu iringprivac
yc
annot
be c
ond u c
te d . T he re appe are d to be no u s e ofapape rbarrierbe twe e n patients on the e xam ination
table s , whic
his an infe c
tion c
ontroliss u e .
R e novations have be gu n in the E as t C e llH ou s e to im prove the s ic
kc
alls e tting. A n ins pe c
tion of
this are aind ic
ate d as ignific
antly im prove d s itu ation and c
ou ld be c
ons id e re d an appropriate
Ju ne 2014
M enard C orrec ti
onalC enter
P age 10
c
linic
als e ttingd e pe nd e nt on prope rly e qu ippingthe are a. H ighpriority s hou ld be plac
e d on the
c
om ple tion ofthis s pac
e and prom pt re novation ofthe re m ainingc
e llhou s e s ic
kc
allare as .
Se gre gation s tatu s inm ate s ac
c
e s s d aily s ic
kc
allin the s am e m anne ras the ge ne ralpopu lation. In
the s e gre gation c
e llhou s e (N orth2)the re is ad e s ignate d s ic
kc
all are athat bothnu rs ings taff
and the phys ician u s e to c
ond u c
t s ic
kc
all. T he room is e qu ippe d withan e xam ination table , and
nu rs ings tafftake s othe re qu ipm e nt and s u pplies ne e d e d fors ic
kc
all. T he nu rs e provid e s alist of
inm ate nam e s to the s e gre gation u nit wingoffic
e rwho the n take s inm ate s one -by-one to the s ic
k
c
allroom for the nu rs e to e valu ate . A s are s u lt, the inm ate be ne fits from aprivate , c
onfid e ntial
e nc
ou nte rwiththe be ne fit ofan appropriate e xam ination ifind ic
ate d . A gain, the O ffic
e ofH e alth
Se rvic
e s approve d protoc
h s ic
kc
all e nc
ou nte r. T he s ic
kc
all e nc
ou nte r is
d oc
u m e nte d in e ac
hd e taine e
s m e d ic
alre c
ord .
Se gre gation we llne s s c
he c
ks are c
ond u c
te d fore ac
hinm ate d aily on the 7a.m . to 3p.m . s hift.
N u rs ings taffad m iniste ringm orningm e d ic
ation proc
eed s c
e ll-to-c
e ll, talkingwithe ac
hinm ate in
s e gre gation s tatu s . D oc
u m e ntation ofthe we llne s s c
he c
kis note d on the s e gre gation log.
Sixte e n ge ne ralpopu lation m e d ic
alre c
ord s we re re viewe d for s ic
kc
alle nc
ou nte rs . O ne patient
c
hos e to go to yard rathe rthan s tay in his c
e llfors ic
kc
all. A s are s u lt, as am ple of15 s ic
kc
all
re c
ord s willbe u s e d .
1. O f the 15 s ic
kc
alle nc
ou nte rs , 10 we re pe rform e d by are giste re d nu rs e and five we re
pe rform e d by alic
e ns e d prac
tic
alnu rs e .
2. O fthe 15e nc
ou nte rs , five re s u lte d in are fe rralto the phys ician, withtwo ofthe five be ing
u rge nt re fe rrals . Fou rofthe re fe rrals we re m ad e by aR N and one by aLP N .
3. O fthe five re fe rrals , two patients we re e valu ate d im m e d iate ly, and the othe rthre e patient
appointm e nts oc
c
u rre d on the d ay s c
he d u le d , and the phys ic
ian or m id -le ve l provid e r
ad d re s s e d the iss u e that le d to the re fe rral.
4. In e ac
hofthe 15e nc
ou nte rs, the O ffic
e ofH e althSe rvic
e s approve d pre-printe d protoc
ol
form was u s e d , the d ate and tim e we re note d , the provide r s ignatu re and title we re note d ,
ed u c
ation was provide d and aphys ic
ale xam ination s pe c
ificto the c
om plaint was note d .
5. In one e nc
ou nte r, the d u ration ofc
om plaint was not note d . T his e nc
ou nte rwas c
ond u c
te d
by aR N .
6. In te n ofthe 15e nc
ou nte rs , c
om ple te vitals igns we re note d . Five e nc
ou nte rs inc
lu d e d no
we ight, and one e nc
ou nte r inc
lu d e d no te m pe ratu re . In the s e e nc
ou nte rs , aLP N d id not
provide the te m pe ratu re and thre e tim e s d id not re c
ord awe ight. A R N d id not re c
ord a
we ight in two ofthe e nc
ou nte rs .
7. In one e nc
ou nte r, the LP N d id not s pe c
ify ale ft orright ankle s prain, and in one e nc
ou nte r
the R N d id not s pe c
ify the loc
ation ofjoint pain.

T he re are 1170 inm ate s e nrolle d in the c
hronicd ise as e program in s e parate c
linic
s . T his is
approxim ate ly 36% ofthe popu lation at C I. T he d istribu tion in c
linic
s is as follows :
C ard iac
Ju ne 2014
M enard C orrec ti
onalC enter
P age 11
D iabe te s (173)
Ge ne ralM e d ic
ine (158)
H IV Infe c
tion/A ID S (33)
Live r(135)
T B Infe c
tion C linic(10)
T he re was no bac
klogin c
hronicc
are c
linic
s at the tim e ofou rvisit. O ne ofthe nu rs e prac
titione rs
is d e vote d e xc
lu s ive ly to c
hronicd ise as e m anage m e nt and is as s iste d by one of the phys ic
ians
d e pe nd ingon volu m e s , whic
hre porte d ly c
an ru n qu ite high(25-30 pe rd ay). W e fou nd the c
are
provide d by this nu rs e prac
titione r to be ofhighqu ality, withagood knowle d ge bas e and s olid
d ec
ision-m akings kills .
P atients withm u ltiple c
hronicd ise as e s are e nrolle d in what the y c
allthe c
om bo c
linic
and all
c
ond itions are ad d re s s e d at e ac
hc
linicvisit. T his s hou ld be (bu t isn
t)the prac
tic
e at allothe r
fac
ilities ;howe ve r, the s c
he d u le r m u s t take into c
ons id e ration the tim e re qu ire d to provid e
thorou ghc
are .
T he c
hronicc
are nu rs e has d e ve lope d and im ple m e nte d ad atabas e u s ingM ic
ros oft A c
c
e s s which
trac
ks d ataforallc
hronicc
are c
linic
s and c
an be u s e d to ge ne rate re ports ofc
ou ntle s s type s . T he
d ata re ac
he s only as far bac
k as A u gu s t 2013 and s o was not ye t ac
om ple te pic
tu re of this
popu lation, bu t willbe able to c
ru nc
hthe d atain innu m e rable and ve ry valu able ways .
A s wond e rfu las this d atabas e has the c
apac
ity to be , it is only as good as the qu ality ofthe d ata
fe d into it. U nfortu nate ly, the provid e rs are not c
ons iste ntly as s e s s ingthe d e gre e of c
ontrol
ac
c
u rate ly, whic
his c
orru ptingthe re liability ofthat portion ofthe d ata. C u rre ntly, it is u s e d only
as aware hou s e ofinform ation, and not as atoolto im prove c
linic
alqu ality as it u ltim ate ly s hou ld
be .
A sec
ond c
hronicc
are nu rs e ru ns allthe infe c
tiou s d ise as e c
linic
s (H IV , he patitis C and T B ). She
seem s c
ons c
ientiou s and organize d .
O f665patients e nrolle d in the c
linic
, 461(69%)we re at goalblood pre s s u re and 195(31%)we re
not at goalat the irm os t re c
e nt c
hronicc
are visit. O fthos e patients whos e blood pre s s u re was not
at goal, 66(34% )had no c
hange in the irplan ofc
are . T his m ay be partly d u e to the way the form
is c
ons tru c
te d . A s part ofthe c
om bo c
linic
form , the provide ris as ke d ifthe blood pre s s u re was
at goalfor 2 ofthe las t 3 re ad ings. T hu s the provid e r is not prom pte d to ad ju s t m e d ic
ations in
re s pons e to an e le vate d blood pre s s u re re ad ingu nle s s the re is apatte rn. R are ly d id we obs e rve the
provide rs to ord e rblood pre s s u re c
he c
ks whe n c
ontrolwas in qu e s tion. T he c
as e be low illu s trate s
this iss u e .
Patient #1
T his is a51-ye ar-old m an withd iabe te s , hype rte ns ion and asthm a. H is blood pre s s u re was at goal
at two ofthe las t thre e c
hronicc
are visits , bu t has be e n e le vate d on m u ltiple oc
c
as ions whe n
Ju ne 2014
M enard C orrec ti
onalC enter
P age 12
he has be e n s e e n by provide rs for othe r iss u e s :150/80, 148/84, 140/94, 140/100 (x 2), 166/94.
N one ofthe s e e le vate d re ad ings we re ad d re s s e d by the provide rs .
Opinion:T hou ghthe patient
s blood pre s s u re has be e n at goald u ringthe c
hronicc
are c
linicvisits ,
it is we llabove goalat alm os t e ve ry othe r c
linic
ale nc
ou nte r. P rovid e rs are not ad d re s s ingthis
patient
s blood pre s s u re , d e s pite d oc
u m e ntingthe e le vate d re ad ings in the irown hand writing.
Diabetes
O f173patients e nrolle d in the d iabe te s c
linic
, 41% we re le s s than we llc
ontrolle d with17(10% )
rate d as poorly c
ontrolle d and 53(31% )u nd e rfair c
ontrol. O u t ofthe 70patients who we re le s s
than we llc
ontrolle d , only 41(59% )had ac
hange in the plan ofc
are . T he fac
ility is s tillu s ingthe
ou td ate d te rm inology ID D M and N ID D M ;this s hou ld c
e as e . U pon arrival, all patients on
phys iologicins u lin re plac
e m e nt (Lantu s , lispro)are au tom atic
ally s witc
he d to N P H and re gu lar
ins u lin re gard le s s ofthe type ofd iabe te s the y have . T his is inappropriate , partic
u larly in the c
as e
ofpatients withtype 1d iabe te s .
ord s of patients e nrolle d in the c
linic
. R ec
ord re view s howe d lac
k of
tim e line s s in two c
as e s and s e ve ralins tanc
e s ofs e riou s proble m s withc
linic
ald e c
ision m aking.
Patient #2
tion and d iabe te s who arrive d at M e nard in Ju ly 2013.
A bou t am onthafte r his arrival, the patient pre s e nte d withad iabe ticfoot u lc
e r. H e was s e e n by
the d oc
torafte rhe had pu lle d his own toe nailoff. T he phys ic
ian d oc
u m e nte d , no ac
tive s ore on
his toe at pre s e nt d e s pite d e s c
ribingahe alinge xpos e d nailbe d . H e ord e re d N eos porin and
follow u pas ne e d e d .
O ne m onth late r, anothe r d oc
tor s aw the patient for what is d e s c
ribe d as agangre nou s toe and
ad m itte d him to the infirm ary forIV antibiotic
s and be tad ine s oaks . D e s pite d e s c
ribingthe le s ion
as r/o gangre ne ,s he d id not ord e rany ad d itionalworku porc
ons u ltations . Finally, the pre viou s
M e d ic
alD ire c
tors aw the patient on 9/24, re c
ognize d the s e ve rity ofthe s itu ation and re fe rre d the
patient to orthope d ics u rge ry foram pu tation, whichwas pe rform e d on 10/2.
Late rin O c
tobe r, his bas e line d iabe te s c
linicwas pe rform e d . It was d e te rm ine d that he is atype 1
d iabe ticwithons e t ofd ise as e in his 20s . H e has be e n s e e n tim e ly in d iabe te s c
linicand was ve ry
we llc
ontrolle d on ac
om bination oforalm e d ic
ations and ins u lin. T he n at the Fe bru ary visit, the
d oc
tor d isc
ontinu e d his ins u lin (he was on 26 u nits of N P H twic
e ad ay), as his las t two A 1c
re ad ings we re le s s than 6% (5.9 and 5.5). W he n he was s e e n again in fou r m onths , his d iabe te s
c
ontrolhad d e te riorate d d ram atic
ally withan A 1cof9.8%. T he d oc
torthe n re s u m e d the ins u lin
and d isc
ontinu e d his oralm e d ic
ation.
Opinion:T his patient was not m anage d aggre s s ive ly e nou ghforhis d iabe ticfoot u lc
e r. T he firs t
d oc
tor appare ntly d id not re c
ognize the im portanc
e oftre atingd iabe ticfoot u lc
e rs aggre s s ive ly
and followingthe m c
los e ly. T he s e c
ond d oc
tor se e m e d able to m ake the c
orre c
t d iagnos is bu t
u nable to form u late an appropriate tre atm e nt plan. H ad this wou nd be e n m anage d prope rly, the
c
hanc
e s ofit progre s s ingto am pu tation wou ld have be e n s u bs tantially re d u c
ed .
Ju ne 2014
M enard C orrec ti
onalC enter
P age 13
D isc
ontinu ingins u lin on atype 1d iabe ticre fle c
ts alac
k ofu nd e rs tand ingofthe bas icphys iology
ofthis d ise as e , whic
his ac
ond ition ofabs olu te ins u lin d e fic
ienc
y.
Patient #3
ontrolle d d iabe te s , hype rte ns ion and hype rlipid e m iawho
has be e n s e e n pe rpolic
y in c
hronicc
are c
linic
. H e was be ingappropriate ly m anage d by the nu rs e
prac
titione rwithim prove m e nt in his d ise as e c
ontrol. T he n, at the D e c
e m be rvisit, he was s e e n by
one ofthe trave llingm e d ic
ald ire c
tors . H is c
ontrolhad d e te riorate d s inc
e the las t c
linicvisit, bu t
no c
A t the A pril2014visit, his A 1cwas 9.8% . T he d oc
torord e re d atre m e nd ou s inc
re as e in his ins u lin
(from 22 to 80 u nits d aily)and qu ad ru ple d the d os e ofhis oralm e d ic
ation. O ne we e k late r, the
patient was at nu rs e s ic
kc
allc
om plainingofhypoglyc
e m iaand havingbe e n re fu s inghis re gu lar
ins u lin forthe las t five d ays . H e was re fe rre d bac
k to the d oc
tor, who ad ju s te d the d os e s d ownward .
Opinion:T his d oc
tor is c
le arly u nfam iliar with the bas icprinc
iple s of ins u lin ad ju s tm e nt and
s e e m ingly obliviou s to the d ange rs ofhypoglyc
e m ia. A n inc
re as e in ins u lin ofthis m agnitu d e (ove r
360% )c
ou ld e as ily have re s u lte d in harm to this patient, inc
lu d ingthe re alpos s ibility ofafatal
hypoglyc
e m ice ve nt. Lu c
kily, the patient had the good s e ns e to re fu s e the m e d ic
ation.
Patient #4
T his is a50-ye ar-old type 1d iabe ticwithhype rte ns ion. H e is be ingtre ate d withnon-phys iologic
N P H ins u lin twic
e ad ay and it is the re fore not s u rprisingthat his d iabe te s is poorly c
ontrolle d . A t
the A pril2013 c
hronicc
are visit, the d oc
tor m ad e no c
hange s to the ins u lin re gim e n d e s pite an
A 1cof9% , bu t rathe r ord e re d aone m onth follow-u p to d ete rm ine if c
hange s s hou ld be m ad e .
T his visit d id not happe n.
H e was not s e e n ford iabe te s again u ntilthe A u gu s t c
hronicc
are c
linic
, at whic
htim e atrave ling
m e d ic
al d ire c
tor inc
re as e d the ins u lin d os e . Six we e ks late r, the patient s aw one of the nu rs e
prac
titione rs in s ic
kc
allc
om plainingofvariable blood glu c
os e and the ins u lin d os e was ad ju s te d
d ownward .
T he ne xt c
hronicc
are visit d id not oc
c
u r u ntilA pril2014, at whic
htim e the patient
s A 1cwas
u nc
hange d at 9.1% . T he nu rs e prac
titione rinc
re as e d the ins u lin and re qu e s te d avisit in two we e ks
to re view the A c
c
u C he c
ks ;this d id not happe n.
s poorly c
ontrolle d d iabe te s has not be e n m anage d aggre s s ive ly e nou gh. A s
are s u lt, he has be e n e xpos e d to the d e le te riou s e ffe c
ts ofhype rglyc
e m iaforove raye ar. Followu pappointm e nts have not oc
c
u rre d as re qu e ste d .
Patient #5
T his is a51-ye ar-old m an withd iabe te s , hype rte ns ion and as thm a. H e has be e n s e e n qu arte rly in
c
hronicc
are c
linicand m anage d appropriate ly, e xc
e pt forthe D e c
e m be r2013visit whe n the form
was c
om ple te ly blank and the patient
s A 1cof9.7% was ignore d .
Patient #6
Ju ne 2014
M enard C orrec ti
onalC enter
P age 15
14
T his is a54-ye ar-old m an with d iabe te s , hype rte ns ion, and paraple gias e c
ond ary to agu ns hot
wou nd . W he n he was s e e n in d iabe te s c
linicin Se pte m be r 2013, his A 1cwas 9.6% , whic
hwas
ac
tu ally be tte rthan the prior re ad ingof12.5% . A s glipizid e had be e n re c
e ntly ad d e d , the nu rs e
prac
titione rd e c
id e d to s e e the patient in thre e m onths be fore d e te rm iningwhe the rto c
hange the
m e d ic
ations . T his follow-u pvisit d id not oc
c
u r. The patient was not s e e n ford iabe te s again u ntil
4/21/14, thou ghhis glipizid e was inc
re as e d from 10twic
e ad ay to 15twic
e ad ay by one ofthe
d oc
tors in N ove m be r. T he re was no note c
orre s pond ingto this c
hange . A t the A prilvisit, the A 1c
was 9.9% and the nu rs e prac
titione rs toppe d the glipizid e and s tarte d ins u lin. She re qu e s te d aone
m onthfollow-u pto re view the blood glu c
os e re ad ings, bu t the patient had not be e n s e e n as ofthe
d ate ofou rvisit on 6/18.
Opinion:T his patient has not be e n s e e n forfollow-u pas re qu e s te d by the nu rs e prac
titione r. T he s e
d e lays are inc
re as inghis e xpos u re to hype rglyc
e m ia
General Medicine
T he re we re fou r patients on C ou m ad in at the tim e of ou r visit. T hre e of the patients s pe nt the
m ajority oftim e in the the rape u ticrange and labs we re d rawn m onthly.
HIV Infection/AIDS
P atients we re ge ne rally s e e n tim e ly by the ID te le m e d ic
ine d oc
torbu t are not c
o-m anage d on s ite ;
this is tru e ofe ve ry s ite we have visite d s o far. W e re viewe d s ix c
harts and fou nd iss u e s with
tim e line s s in two c
as e s T he re we re afairnu m be rofc
anc
e llations d u e to e qu ipm e nt m alfu nc
tion.
Patient #7
T his is a60-ye ar-old H IV patient withas thm a. H e is allowe d to c
arry his H IV m e d ic
ations e ve n
thou gh he is on m e ntalhe alth m e d ic
ations whic
h are d ire c
tly obs e rve d . M A R s re ve althat the
m e d ic
ations have be e n d ispe ns e d to the patient m onthly. H owe ve r, he d e ve lope d an inc
re as e d viral
load in Se pte m be r2013afte rhavingbe e n s u ppre s s e d on the s am e re gim e n, thu s raisingc
onc
e rn
fornonc
om plianc
e . T he ID d oc
torre c
om m e nd e d s toppingthe m e d ic
ations and c
he c
kingan H IV
ge notype . H e wante d to s e e the patient bac
k in 2-3we e ks .
T he patient was s e e n s ix we e ks late rbu t the viralload was not highe nou ghto d o age notype and
had to be re pe ate d . T he re s u lts we re pe nd ingat the tim e ofthis visit. H e re c
om m e nd e d c
ontinu ing
to hold the m e d ic
ations and follow-u pin two we e ks . H owe ve r, the patient was not s e e n again u ntil
M arc
h2014, as the ID te le m e d ic
ine c
linichad be e n c
anc
e le d onc
e d u e to e qu ipm e nt m alfu nc
tion
and onc
e d u e to we athe r.
W he n he was finally s e e n on 3/17, the labs from O c
tobe r we re re viewe d , and s howe d ne w
re s istanc
e m u tations to his pre viou s re gim e n. H e was s tarte d on ne w m e d ic
ations and the s e too
we re d ispe ns e d to him . Follow u pwas ord ere d fors ix we e ks bu t he was not s e e n d u e to proble m s
withthe e qu ipm e nt. H e had not be e n s e e n as ofthe d ate ofou rvisit 6/17.
Opinion:T his patient has not be e n s e e n tim e ly in ID te le m e d ic
ine d u e to avoidable d e lays . T his
patient s hou ld be on D O T in ord e rto m ore c
los e ly m onitorhis m e d ic
ation ad he re nc
e;
d e ve lopm e nt of re s istanc
e is highly s u gge s tive of nonc
om plianc
e . T his patient s hou ld be c
om anage d ons ite by afac
ility provid e r.
Ju ne 2014
M enard C orrec ti
onalC enter
P age 16
Patient #8
T his is a51-ye ar-old m an with H IV infe c
tion and as thm a. H e d e ve lope d pe rs iste ntly low le ve l
vire m iain A u gu s t 2013 d e s pite 100% c
om plianc
e on d ire c
tly obs e rve d the rapy. T he ID d oc
tor
was initially not c
onc
e rne d , bu t whe n it pers iste d at the D e c
e m be r 2013 visit, he re c
om m e nd e d
re pe atingthe te s t im m e d iate ly and followingu p in two we e ks . T hat visit d id not oc
c
u r d u e to
e qu ipm e nt m alfu nc
tion, the n again d u e to we athe r. H e was not s e e n again u ntilM arc
h2014.
Opinion:T his patient has not be e n s e e n tim e ly by the ID d oc
tord u e to avoidable d e lays .
Pulmonary Clinic
O fthe 350 patients e nrolle d in the c
linic
, none we re rate d as poorly c
ontrolle d , e ve n thou gh52
(15% )had pe rs iste nt s ym ptom s . W e re viewe d five re c
ord s ofpatients withpu lm onary d ise as e s
and fou nd that in e ac
hc
as e e ithe r the patient
s d e gre e of c
ontrol was ove re s tim ate d , or his
m e d ic
ations we re not ad ju s te d in re s pons e to his s ym ptom s , or both. T he c
hronicc
are form is
d e s igne d for as thm a, not C O P D ;this is afu nc
tion of the s tate wide tre atm e nt gu ide line which
s pe aks only to as thm a. T he tre atm e nt gu id e line allows forove re s tim ation ofd ise as e c
ontrolwhe n
c
om pare d with nationally pu blishe d gu id e line s , inc
lu d ingthe N ationalH e art, Lu ng, and B lood
Ins titu te (N H LB I)E xpe rt P ane lR e port 3 (E P R 3)u pon whic
h it appe ars the s tate gu ide line is
bas e d . T he c
as e s be low illu s trate the s e iss u e s .
Patient #9
T his is a51-ye ar-old m an withd iabe te s , hype rte ns ion and as thm a. A t the A u gu s t 2013visit, the
patient re porte d s ym ptom s c
ons iste nt with m ild pe rs iste nt asthm a, with d aytim e s ym ptom s and
albu te rolu s e m ore than twic
e we e kly bu t was ju d ge d to be u nd e r good c
ontroland no c
hange s
we re m ad e . A t the D e c
e m be rc
om bo visit, as thm awas not ad d re s s e d at allby the trave lingM e d ic
al
D ire c
tor. A t the A pril2014 visit, the patient
s as thm as e ve rity was not d oc
u m e nte d by the nu rs e
prac
titione r, who d e c
ide d that the patient was in good c
ontrol.
s s ym ptom s we re not ad e qu ate ly d oc
u m e nte d at two ofthe las t thre e c
hronic
c
are c
linic
s . O n at le as t one oc
c
as ion, his d ise as e c
ontrolappe are d to be wors e than the provide r
re c
ognize d .
Patient #10
T his is a60-ye ar-old H IV patient withas thm a. H e has be e n s e e n qu arte rly in c
hronicc
are c
linic
bu t his d e gre e ofc
ontrolhas not be e n as s e s s e d ac
c
u rate ly. Fore xam ple , at the D e c
e m be rc
om bo
c
linic
, he re porte d d aily be taagonist u s e and d aily d aytim e s ym ptom s as we llas s om e lim itation
withnorm alac
tivity, ye t the d oc
torrate d this as good c
ontrol.
A t the Ju ne 2014c
hronicc
are c
linicvisit, the patient re porte d s ym ptom s c
ons iste nt withm od e rate
pe rs iste nt C O P D (d aily albu te rolu s e , d aily d aytim e s ym ptom s , wakingm ore than onc
e we e kly
and s om e lim itation ofnorm alac
tivity), and had e xpiratory whe e z ingon e xam , ye t was rate d as
good c
ontrolby the c
ove ringd oc
tor.

s as thm ahas not be e n ac
c
u rate ly as s e s s e d . It is like ly he wou ld be ne fit from
m ore aggre s s ive as thm athe rapy. P art ofthe proble m he re is that the c
ontrolc
rite rialiste d on the
form allowe d the d oc
tors to d raw the inappropriate c
onc
lu s ion:
Patient #11
tion and as thm a. A t the D e c
e m be r 2013 c
hronicc
are
visit, the c
ove ringd oc
torobtaine d ne arly no historic
alinform ation and the form is alm os t blank.
A t the Fe bru ary 2014 visit, the nu rs e prac
titione r note d that the patient was havingd aytim e
s ym ptom s and u s inghis re s c
u e inhale r le s s than d aily bu t m ore than two d ays pe rwe e k. H e was
rate d as good c
ontrol. A t the Ju ne visit, the trave lingM e d ic
al D ire c
tor d oc
u m e nte d m inim al
inform ation bu t rate d him as good c
ontrol.
Opinion:T his patient was not ad e qu ate ly e valu ate d at two ofthe thre e m os t re c
e nt c
hronicc
are
c
linic
s . H is d ise as e c
ontrolhas be e n ove re s tim ate d ac
c
ord ingto nationally pu blishe d gu id e line s .
Patient #12
T his is a68-ye ar-old m an with s e ve re C O P D and hype rte ns ion. T he re have be e n d e lays in his
c
hronicc
are follow-u pappointm e nts and he has be e n s e e n s e ve raltim e s forC O P D e xac
e rbations .
T he s e are not m e ntione d d u ringhis c
hronicc
are visits and althou ghhis s ym ptom s are m od e rate to
s e ve re , the re have be e n no c
hange s to his bas e line pu lm onary m e d ic
ations .
s d ise as e s hou ld be m anage d m ore aggre s s ive ly c
ons id e ringhis poorc
ontrol.
Patient #13
T his is a33-ye ar-old m an withm od e rate pe rs iste nt as thm awho has be e n s e e n qu arte rly in c
hronic
c
are c
linic
. T he re have be e n no c
hange s to his m e d ic
ation re gim e n d e s pite his re pe ate d
Ju ne 2014
M enard C orrec ti
onalC enter
P age 17
re ports ofd aily s ym ptom s and re s c

u e inhale ru s e , as id e from the ad d ition ofC laritin at his m os t
re c
e nt c
linicvisit.
s tre atm e nt re gim e n s hou ld be inte ns ified c
ons id e ringhis re ports ofd aily
s ym ptom s .
Seizure Clinic
N one ofthe 54patients e nrolle d in the s e izu re c
linicwere d e e m e d to be in poorc
ontrol. T his m ay
be be c
au s e patients re ports ofbre akthrou ghs e izu re s m ay be d isc
ou nte d ifthe y are not witne s s e d
by s taff. O fthe s ix patients who re ported s e izu re s s inc
e the las t c
linicvisit, only two had ac
hange
ofc
are d oc
u m e nte d . W e re viewe d fou rre c
ord s ofpatients e nrolle d in the s e izu re c
linicand fou nd
d e lays in c
are and opportu nities forim prove m e nt in two c
as e s d e s c
ribe d be low.
Patient #14
T his is a 57-ye ar-old m an with s e izu re s , hype rlipide m ia, and aorticvalve re plac
e m e nt. H e is
c
hronic
ally antic
oagu late d withC ou m ad in. H e has only be e n s e e n twic
e in c
hronicc
are c
linicin
the pas t ye ar. A t the Se pte m be r 2013 visit, his D ilantin le ve lwas s u bthe rape u ticat 6.5 and he
re porte d 7-8s e izu re s s inc
e the las t visit, bu t none are d oc
u m e nte d in the he althre c
ord . H is D ilantin
is s e lf-c
arried and has be e n d ispe ns e d to him m onthly, thou gh he ge ts his C ou m ad in nu rs e ad m iniste re d .
A t the ne xt c
hronicc
are c
linicon 5/8/14, he re porte d one bre akthrou ghs e izu re , thou ghagain it
was not d oc
u m e nte d in the he alth re c
ord . H is m os t re c
e nt D ilantin le ve l was e ve n m ore
s u bthe rape u ticon 3/28/14 at 4.5. T he d oc
tor re c
om m e nd e d that the d os e be inc
re as e d bu t the
patient re fu s e d .
Opinion:T his patient s hou ld be on D O T to m onitorhis m e d ic
ation ad he re nc
e m ore c
los e ly. H e
alre ad y re c
e ive s D O T forhis C ou m ad in. H e has not be e n s e e n tim e ly in c
hronicc
are c
linic
.
Patient #15
T his is a47-ye ar-old m an with hype rte ns ion, H IV and abs e nc
e s e izu re s who re ports fre qu e nt
bre akthrou ghs e izu re ac
tivity d e s pite the rape u ticm e d ic
ation le ve ls . T he d os e was inc
re as e d onc
e
d u ringthe pas t ye ar bu t he c
ontinu e d to re port s e izu re ac
tivity. T his has e vid e ntly only be e n
witne s s e d by the patient
sc
e llie. H e has be e n s e e n rou ghly qu arte rly in c
hronicc
are c
linic
. A t the
D ec
e m be r 2013 c
linic
, the d oc
tor
s note c
ontains alm os t no history and the m e d ic
ation was
re ord e re d inc
orre c
tly, d e c
re as ing the d os e by half. T his was c
au ght by the pharm ac
y who
qu e s tione d the c
hange , and the patient was re fe rre d to the nu rs e prac
titione r, who re fe rre d the
patient bac
k to the pre s c
ribingd oc
tor. It took two m onths forthe patient to be s e e n by the d oc
tor
and have the m e d ic
ation d os e c
larified .
Opinion:T his patient s hou ld not have waite d two m onths to have his m e d ic
ation d os e c
larified .
E ve n whe n his le ve ls we re the rape u tic
, his s e izu re s d id not appe arto be u nd e rc
ontrol. C ons id e r
s witc
hingthis patient to anothe rm e d ic
ation.
Ju ne 2014
M enard C orrec ti
onalC enter
P age 18
TB Infection Clinic
T he re we re e ight patients on tre atm e nt forlate nt TB infe c
tion (LT B I)at the tim e ofou rvisit, fou r
of whom appe are d to have c
onve rte d the ir s kin te s ts at M e nard (s e e P atients #1-4 be low). W e
d isc
u s s e d the s e withthe H C U A , who s tate d that ac
ontac
t inve s tigation was pe rform e d fortwo of
the patients who had be e n hou s e d in the s am e u nit and no s ou rc
e was ide ntified . It was he ropinion
that the othe rs we re not re ad properly to be gin with(i.e ., fals e ne gative s )and s o we re not ne w
c
onve rs ions bu t rathe r m iss e d on the initials kin te s t. W hile this is pos s ible , s u c
han as s u m ption
s hou ld not pre c
lu d e s om e form ofinve s tigation. W e d id not have the opportu nity to d isc
u s s this
withthe infe c
tion c
ontrolnu rs e who was ou t on m e d ic
alle ave .
In two othe rc
as e s (P atients #7and #8), patients we re pre s c
ribe d tre atm e nt whe n it was not c
le ar
that the y tru ly re qu ire d it.
A llre ac
tive te sts are re ad by two nu rs e s and aprovid e r.
Patient #16
T his is a22-ye ar-old m an who was re c
e ive d at N R C on 2/7/12at whic
htim e he was d oc
u m e nte d
to be P P D ne gative . H e was trans fe rre d to M e nard on 5/1/13. O n 4/7/14, his annu alT B s kin te s t
was 10 m m re ac
tive . N o c
ontac
t inve s tigation was d oc
u m e nte d in the he alth re c
ord . U pon
qu e s tioningby the provide r, the patient d e nied ahistory ofprior pos itive s kin te s ts . T he patient
was re fe rre d forT B tre atm e nt and had appropriate pre -tre atm e nt work-u pand c
linic
ale valu ation.
H e s tarte d m e d ic
ations on 5/19/14.
Patient #17
e ive d at Graham on 2/26/13and trans fe rre d to M e nard on
3/20/13. O n re c
e ption, his P P D was re ad as ne gative . H is ye arly P P D was plac
e d at M e nard on
3/4/14and was re ad as ne gative . Forre as ons that are not c
le arfrom c
hart d oc
u m e ntation, the P P D
was re pe ate d on 5/5/14and was re ac
tive at 18m m . N o c
ontac
u m e nte d . H e
was appropriate ly e valu ate d fortre atm e nt on 5/14/14and tre atm e nt was ord e re d .
Patient #18
e ive d at N R C on 10/4/12 and trans fe rre d to M e nard on
10/17/12. H is P P D was re ad as ne gative on intake . H is annu alP P D at M e nard on 1/7/13was re ad
as ne gative . Foru nc
le arre as ons , it was re pe ate d on 1/16/13and was again re ad as ne gative . A ye ar
late r, his annu alP P D was re ac
tive at 16m m on 3/4/14. H e was s e e n by the d oc
torand re fe rre d to
TB c
linicfortre atm e nt. O n 5/1, the patient told the d oc
torthat his te s t was not pos itive , that it was
his c
e llie
s te s t that was re ac
tive . T he te s t was the re fore re pe ate d on 5/5 and was re ac
tive at 22
m m . H e was re fe rre d bac
k to the d oc
torforpretre atm e nt e valu ation and the rapy was ord e re d . N o
c
ontac
u m e nte d .
Patient #19
T his is a44-ye ar-old m an who arrive d at M e nard re c
e ption in A u gu s t 2013bu t was not te s te d for
T B , as it was note d that he was nonre ac
tive pe rthe jailre c
ord s . W he n he was ne xt te ste d on 3/1/14,
he was re ac
tive at 12m m . H e was e valu ate d appropriate ly by the d oc
torand s tarte d tre atm e nt on
3/18. H e has be e n s e e n m onthly by the ID c
linicnu rs e .
Patient #20
Ju ne 2014
M enard C orrec ti
onalC enter
P age 20
19

e ive d throu ghM e nard
s re c
e ption c
e nte rin Fe bru ary 2014
and was note d to be re ac
tive on intake . H e was ad m itte d to the infirm ary by ve rbalord e rofthe
M e d ic
alD ire c
tor whe n the re ad ingR N note d the pos itive te s t. T he M e d ic
alD ire c
tor s aw the
patient the ne xt d ay, took no history, and d oc
u m e nte d am inim alphys ic
ale xam . U pon qu e s tioning
by the nu rs e , the patient re porte d that he had ahistory of+P P D , bu t this box was c
he c
ke d noon
the intake s c
re e ningform . A c
he s t x-ray was pe rform e d as part ofthe pretre atm e nt work-u pand
s howe d aright hilarm as s vs ad e nopathy as we llas ad d itionalad e nopathy in the right paratrac
he al
re gion. H e was awaitingaC T s u rge ry c
ons u lt forbiops y as ofthe tim e ofou rre view. O n 5/12/14,
he was s e e n by the M e d ic
al D ire c
tor for his bas e line T B c
linicand was pre s c
ribe d IN H and
rifam pin (rathe rthan rifape ntine )we e kly for12we e ks . H e was the n ano-s how forhis follow u p
TB c
linicon 6/17.
Opinion:T his patient appe ars to have bigge rproble m s than his late nt T B infe c
tion. T he pre s c
ribing
e rrorwas brou ght to the atte ntion ofthe M e d ic
alD ire c
torforc
orre c
tion. T he re s hou ld be no s u c
h
thingas ano-s how in am axim u m s e c
u rity prison.
Patient #21
T his is a31-ye ar-old who was re c
e ive d at N R C on 11/6/13and trans fe rre d to M e nard on 3/20/14.
H e d id not have aP P D plac
e d at the re c
e ption c
e nte r bu t rathe r ac
he s t x-ray d u e to rapid
tu rnarou nd ofthis R & C inm ate .N o one at M e nard kne w the m e aningofthis. A fte rhe arrive d at
M e nard , his P P D was re ac
tive at 19m m . H e was appropriate ly e valu ate d and s tarte d on tre atm e nt
on 5/28/14.
Patient #22
T his is a50-ye ar-old m an who had apos itive P P D on re c
e ption at N R C on 1/12/07. H e was
trans fe rre d to M e nard in Fe bru ary 2007 and was e vid e ntly not offe re d tre atm e nt (the s e re c
ord s
we re thinne d from the c
u rre nt volu m e ). T he re we re no P P D te s ts d oc
u m e nte d on the d atabas e for
20082012. H e was s c
re e ne d in D e c
e m be r2013by s ym ptom as s e s s m e nt, pre s u m ably d u e to his
history ofaprior pos itive s kin te s t. H e the n had aP P D plac
e d on 2/13/14, whic
hofc
ou rs e was
re ac
tive at 20m m . T he M e d ic
alD ire c
tors aw him forhis bas e line T B c
linicon 2/18and took no
s ym ptom history, bu t ord e re d labs and ac
he s t x-ray. H e s aw the patient bac
k on 3/27, at whic
h
tim e the patient re porte d re c
e ivingB C G as ac
hild . T re atm e nt was ord e re d . H e was s e e n m onthly
the re afte rby the T B c
linicnu rs e .
Opinion:P atients withahistory ofpriorpos itive s kin te s tings hou ld not have re pe at te s ting. Give n
his history ofB C G vac
c
ine , this patient s hou ld probably have gotte n alte rnative te s tingwithan
inte rfe ron gam m aas s ay s u c
h as the qu antife ron gold to d ete rm ine his e xpos u re s tatu s prior to
c
om m ittinghim to tre atm e nt withm e d ic
ations that have pote ntialtoxic
ities . T he s tate T B gu id e line
is s ile nt on the iss u e ofwhe n and whe the rto u s e the inte rfe ron gam m ate s ts , bu t rathe rle ave s it to
the d isc
re tion ofthe provide rs . It is the re fore im portant that provide rs have an u nd e rs tand ingof
the variou s m e thod s ofs c
re e ningforLT B I and whe n to u s e the m .
Patient #23
T his patient re porte d apos itive P P D u pon re c

e ption at N R C in A pril2014and that he had re c
e ive d
tre atm e nt in 1999. D e s pite this history, anothe r P P D was plac
e d whe n he trans fe rre d to M e nard
and was , not s u rprisingly, pos itive . H e was the n re fe rre d fortre atm e nt.
Opinion:T he re s hou ld have be e n an e ffort to c
onfirm the patient
s history ofpriorT B tre atm e nt
priorto c
om m ittinghim to the rapy withm e d ic
ations withpote ntialtoxic
ities .
B os we llP harm ac
e u tic
als , loc
ou nte r
m e d ic
ations for the fac
e ns e d as a W hole s ale D ru gD istribu tor/P harm acy
D istribu torand has ac
u rre nt lic
e ns e throu ghM arc
h2016. T he s e rvic
e is afax and fills ys te m ,
whic
h m e ans patient ne w pre s c
riptions faxe d to the pharm ac
y by noon M ond ay throu ghFriday
willarrive at the fac
ility the ne xt d ay. T he fac
ility re c
e ive s m e d ic
ation d e live ries s ix d ays awe e k,
M ond ay throu gh Satu rd ay. A loc
al re tail pharm ac
y and the loc
al hos pital are the bac
k-u p
pharm ac
ies forobtainingm e d ic
ation whic
k.
P atient s pe c
ificpre s c
riptions , s toc
k pre s c
riptions and c
ontrolle d m e d ic
ations arrive pac
kage d in a
30-d ay bu bble pac
k. O ve r-the -c
ou nte r m e d ic
ations are provide d in bu lk by the bottle , tu be , e tc
.
T he m e d ic
ation pre paration/storage are ais s taffe d withtwo fu ll-tim e pharm ac
y te c
hnic
ians ;one
has 20 ye ars of e xpe rienc
e , and the othe r has e ight ye ars of e xpe rienc
e . B os we ll provid e s a
c
ons u ltingpharm ac
ist to c
om e on-s ite onc
e am onth to re view pre s c
ription ac
tivity, to as s e s s
pharm ac
y te c
hnic
ian pe rform anc
e and te c
hniqu e and to d e s troy ou td ate d or no longe r ne e d e d
c
ontrolle d m e d ic
ations pu rs u ant to the re qu ire m e nts ofthe Fe d e ralD ru gA d m inistration (FD A )
and D ru gE nforc
e m e nt A ge nc
tion of the m e d ic
ation pre paration/storage are a
re ve ale d a large , c
le an, organize d , we ll-lighte d and we ll-m aintaine d are a. Inte rviews with the
pharm ac
y te c
hnic
ians re ve ale d knowle d ge able ind ivid u als . Fu rthe rins pe c
ate d
tight ac
c
ou ntingofc
ontrolle d m e d ic
ations , boths toc
k and retu rn ite m s . A rand om ins pe c
tion of
pe rpe tu alinve ntories and c
ou nts forc
ontrolle d m e d ic
ation ind ic
ate d allwe re c
orre c
t.
A c
c
te d to the two pharm ac
y te c
hnic
ians and the c
e ntral
s u pply s u pe rvisor. A llthre e are re qu ire d to d raw ke ys to the irre s pe c
tive are as at the be ginningof
e ac
hs hift and re tu rn the ke ys whe n le avingat the e nd ofthe irs hift. In the e ve nt the y wou ld le ave
ins titu tionalgrou nd s withthe ke ys , the y are c
ontac
te d by arm ory pe rs onne lto im m e d iate ly re tu rn
to the ins titu tion. K e ys to the bac
k s toc
k c
age d are a are re stric
te d to the two pharm acy
te c
hnic
ians . R e frige ratorte m pe ratu re s are m onitore d and d oc
u m e nte d d aily.
A ll pre s c
riptions and c
ontrolle d m e d ic
ations are ord e re d , re c
e ive d and inve ntoried by the
pharm ac
y te c
hnicians . O nc
e re c
e ive d and c
hofthe ite m s is ad d e d into the ite m
s pe c
e d in bac
k s toc
kare s tore d in aloc
ke d c
age are ains id e
the loc
ke d and re s tric
te d ac
c
e s s s torage room . T he pe rpe tu alinve ntories forallite m s loc
ate d in
the c
age are ve rified we e kly by the pharm ac
y te c
hnic
ians . P e rpe tu alinve ntories for c
ontrolle d
m e d ic
kare ve rified e ac
hs hift by on-c
om ingand off-goingnu rs ing
s taff. T he c
ras hc
art, loc
ate d in the u rge nt c
are are a, is inve ntoried we e kly orany tim e the plas tic
sec
u rity s e alis broke n. C ontrolle d m e d ic
ations , s yringe s /ne e d le s and m e d ic
altools in this are a
are inve ntoried at the be ginningand e nd ofe ac
hs hift by on-c
om ingand off-goingnu rs ings taff.
Ju ne 2014
M enard C orrec ti
onalC enter
P age 21
In the abs e nc
e ofthe pharm ac
y te c
hnic
ians , nu rs ings taffc
an ac
c
e s s the pharm ac
y s torage are a,
inc
lu d ingthe c
age are a, to obtain ne e d e d m e d ic
ation only by c
ontac
tingthe Shift C om m and e rwho
au thorize s aLieu te nant to d raw the ke ys to the are a. T he Lieu te nant re ports to the he althc
are u nit
and u nloc
ks the d oors forthe nu rs e . B oththe Lieu te nant and nu rs e are re qu ire d to s ign into the
pharm ac
y on aP harm ac
y Lognotingthe d ate, tim e , nam e , title , re as on for e nte ringand tim e
le aving. T he nu rs e obtains the ne e d e d m e d ic
ation, le ave s anote as to whic
hite m s we re re m ove d
and is re qu ire d to c
om ple te an Inc
id e nt R e port as to the ne e d fore nte ringthe are a. T he Lieu te nant
sec
u re s the d oors and retu rns the ke ys to the arm ory. T he ne xt m orning, the pharm ac
y te c
hnic
ians
c
ond u c
t ac
ou nt ofallite m s on ape rpetu alinve ntory.
T he c
e ntrals u pply s u pe rvisor, who has be e n in the pos ition 18 m onths , is re s pons ible to ord e r,
re c
e ive and m aintain pe rpe tu alinve ntories on alls yringe s /ne e d le s , s harpins tru m e nts and m e d ic
al
tools . W ithin the c
e ntral s u pply are a is a c
age d are a whe re the bac
k s toc
k s u pply of
s yringe s /ne e d le s , s harp ins tru m e nts and m e d ic
al tools are s tore d . A pe rpe tu al inve ntory is
m aintaine d for e ac
hite m . P e rpe tu alinve ntories are ve rified m onthly. K e ys to the c
e ntrals u pply
are aare re s tric
te d to the s u pe rvisorand ad m inistrative as s istant. N u rs ings taffc
an e nte rthe are a
afte rhou rs u nd e rthe s am e proc
e d u re s fore nte ringthe m e d ic
ation s torage are a.
D os e -by-d os e m e d ic
e ns e d nu rs ings taff. M e d ic
ation is d e live re d to
inm ate s and ad m iniste re d d os e -by-d os e at c
e lls id e . N u rs ings taffobtains one d os e ofm e d ic
ation
from the patient s pe c
ificbliste rpac
k and plac
e s it in apille nve lope whic
hhas be e n hand labe le d
withthe patient
s nam e and nu m be r, the nam e ofthe m e d ic
ation, s tre ngth, d os age and tim e to be
ad m iniste re d . T he nu rs e c
arries the e nve lope s to the c
e llhou s e and is e s c
orte d by s e c
u rity s taff
c
e llto c
e ll. A t e ac
hc
e ll, the inm ate is re qu ire d to c
om e to the c
e lld oor, s how his ide ntific
ation
c
ard , s tate his nam e and have s om e thingto d rink. T he nu rs e pos itive ly id e ntifies the inm ate , give s
him the m e d ic
ation, obs e rve s inge s tion and pe rform s am ou thins pe c
tion. W he n c
om ple te d , the
nu rs e re tu rns to the he althc
are u nit and d oc
u m e nts ad m inistration orre fu s alofthe m e d ic
ation on
e ac
hpatient s pe c
ificm e d ic
ord (M A R ).
Lic
e ns e d nu rs ings taff goe s to the c
e ll hou s e s be twe e n 2:30 a.m . and 3:30 a.m . to ad m iniste r
m orningins u lin. Inm ate s are s e rve d bre akfas t in the ir c
e llbe twe e n 4:30 a.m . and 5:00 a.m . T he
e ve ning ins u lin is provid e d be twe e n 1:30 p.m . and 2:30 p.m . with d inne r be ing s e rve d at
approxim ate ly 3:00p.m .
Laboratory
Laboratory s e rvic
ago H os pital(U IC ). T wo
fu ll tim e phle botom ists d raw and pre pare the s am ple s for trans port to U IC . R e s u lts are
e le c
tronic
k to the fac
ility, ge ne rally within 24hou rs vias e c
u re fax line loc
ate d
in the m e d ic
ald e partm e nt. U IC re ports allre portable c
as e s both to the fac
ility and the Illinois
D e partm e nt of P u blicH e alth. T he re is ac
u rre nt C linic
alLaboratory Im prove m e nt A m e nd m e nt
(C LIA )waive r c
e rtific
ate that e xpire s Janu ary 27, 2016, on file . T he re we re no re ports of any
proble m s withthis s e rvic
e.
Ju ne 2014
M enard C orrec ti
onalC enter
P age 22
Urgent/Emergent Care/Unscheduled Offsite Services

ord s of patients s e nt ou t for e m e rge nc
ies . M ore than half d e m ons trate d
s ignific
ant d e fic
ienc
ies . In ge ne ral, the d e fic
ienc
ies re late d to inad e qu ate follow u p, som e tim e s
re late d to the abs e nc
e ofavailability ofappropriate pape rwork and als o inad e qu ate m onitoringof
patients who are hos pitalize d afte rm ajorproc
e d u re s . T he m onitoringd e fic
ienc
ies be gan withthe
nu rs ings taff.
Patient #1
T his is a 57-ye ar-old with hype rte ns ion, he patitis C d ise as e and s u bs tanc
e abu s e iss u e s . H e
pre s e nte d on 3/28/14to s ic
kc
allc
om plainingoflowe rabd om inalpain, ac
hingand bu rningwith
five loos e stools . H e was s e e n by aC M T , whic
his c
om ple te ly inappropriate s inc
e he s hou ld have
be e n as s e s s e d , at am inim u m , by anu rs e oram id le ve lprovid e r. H e was re fe rre d to the phys ic
ian
the ne xt d ay and whe n s e e n by the phys ic
ian he was im m e d iate ly s e nt ou t to ru le ou t ac
u te
appe nd ic
itis. In fac
t, he had an ac
u te appe nd e c
tom y and was re tu rne d on 3/31, and afte r an
as s e s s m e nt by the M e d ic
alD ire c
tor, was s e nt to his c
e ll. A lthou ghthe re was are c
om m e nd ation
for him to be followe d u p at the hos pitalthis ne ve r happe ne d , nor is the re any note ind ic
atinga
c
hange from that re c
om m e nd ation.
Patient #2
T his is a61-ye ar-old withos teoporos is who was s e nt ou t on 1/26/14. O n that d ay at abou t 2:10
p.m ., he c
om plaine d ofc
he s t pain fortwo hou rs . H e d e s c
ribe d it as apre s s u re in his c
he s t and was
give n nitroglyc
e rin, withs om e re lief. H is blood pres s u re was e le vate d at 154/90and his pu ls e rate
was 116. T he phys ic
ian was c
alle d and the ord e rwas to s e nd him to the hos pital. T he patient we nt
to the hos pitaland re tu rne d one we e k late ron 2/3and was plac
e d in the infirm ary forobs e rvation.
H e was s e e n that d ay by the nu rs e who d id not as k any qu e s tions re gard ingc
he s t pain, s hortne s s
ofbre athorany inc
ision proble m s . H e was the n s e e n by anu rs e prac
titione rwhos e note ind ic
ate s
history ofre c
e nt c
oronary arte ry bypas s graft s u rge ry bu t no s u bje c
tive d atais e licite d from the
patient. T he patient was u ltim ate ly re le as e d to the c
e ll. T he re c
ord s till lac
ks any d isc
harge
s u m m ary or, m ore im portantly, the c
athe te rization and e c
ho re ports , c
ritic
alpiec
e s that s hou ld be
part ofthe m e d ic
alre c
ord .
Patient #3
T his is a30-ye ar-old who on 5/4/14was ad m itte d to the infirm ary priorto am e d ic
alfu rlou ghfor
ale ft ingu inalhe rniare pair. T he re pairwas d one on 5/5and afte rthe patient retu rne d , he we nt to
his c
e ll. O n 5/6, one d ay late r, he c
om plaine d ofblood y d iarrhe aand was plac
e d in the infirm ary
forobs e rvation. H e was the n ad m itte d to the infirm ary and on 5/9was s e nt to C arbond ale H os pital
as an e m e rge nc
y fu rlou gh. H e staye d in C arbond ale H os pitalfor awe e k afte r be ingd iagnos e d
with s e ve re c
olitis from the re c
tu m to the he paticfle xu re , bu t in ad d ition he had as e izu re , for
whic
hthe work-u pwas ne gative . H e retu rne d to the infirm ary on 5/16and again the nu rs e note s
on m onitoringc
ontain virtu ally no qu e s tions re gard inghis c
u rre nt s ym ptom atology in re lations hip
to the proble m s for whic
hhe was s e nt ou t. H e staye d in the infirm ary for awe e k and the n was
followe d u pas an ou tpatient.
Patient #4
T his is a48-ye ar-old withhype rte ns ion and glau c
om a. T hos e are the only d iagnos is liste d on the
proble m list. O n 1/13/14, he c
om plaine d ofc
he s t pain and was s e nt to the hos pital. T he work-u p
Ju ne 2014
M enard C orrec ti
onalC enter
P age 23
at the hos pitalwas ne gative forac

u te c
oronary artery d ise as e and the d iagnos is was re flu x d ise as e .
H e retu rne d from the hos pitaland at the tim e ofre tu rn his vitals igns we re norm al. T he re is an
ord erforan e le c
troc
ard iogram and aphys ic
ian as s e s s m e nt. T he c
ard iogram was s c
he d u le d forthe
th
17 , bu t it was not d one be c
au s e ofloc
kd own. In fac
t, it was not d one u ntile ight d ays late rand at
the tim e ofou rvisit, the re was s tillno c
ard iogram in the c
hart. T his is apatient who had apre viou s
history ofbothahe art attac
k and s u prave ntric
u lartac
hyc
ard ia, althou ghne ithe rofthe s e proble m s
we re on the proble m list. A n E K G was ord e re d bu t it was d e laye d u nac
c
e ptably, and in fac
t fou r
m onths late rthe re was no re port in the c
hart.
Patient #5
T his is a48-ye ar-old withas thm awho was s e nt ou t on 3/14/14in ord e rto ru le ou t an ac
u te stroke .
H e was s e e n by the M e d ic
alD ire c
tor on 3/14 c
om plainingof c
he s t pain, bu t at that visit the
M e d ic
alD ire c
tor notic
e d that he s e e m e d to have e xpre s s ive aphas iaand afac
iald roop. H e was
s e nt to the hos pital and re tu rne d two d ays late r. U pon re tu rn his blood pre s s u re was 144/98,
ind ic
atinghype rte ns ion. H e was s e e n the followingd ay, on 3/17, withad iagnos is ofas troke and
re flu x d ise as e . H is blood pre s s u re was re c
he c
ke d on 5/28 and it was s ignific
antly e le vate d at
165/88. H e was s u ppos e d to be s e e n on 5/29, bu t this d id not oc
c
u r. H e was re fe rre d to aphys ic
ian
on 5/23, bu t this d id not happe n d u e to c
u s tod y e m e rge nc
ies . H e was in fac
t not s e e n u ntil6/13, at
whic
hpoint his le gs we re s wolle n. A blood pre s s u re c
he c
k two tim e s awe e k fortwo we e ks had
be e n ord e re d , bu t the re we re no blood pre s s u re c
he c
ks pe rform e d or available in the m e d ic
al
re c
ord . T his is apatient pote ntially at risk forwhom follow throu ghd id not oc
c
u r.

A s we u nd e rs tand the proc
e s s , all re fe rrals by ons ite phys ic
ians or m id le ve l prac
titione rs are
re fe rre d to the M e d ic
alD ire c
tor, who e ithe r approve s the m and pre s e nts the m at the c
olle gial
re view or te lls the ord e ringc
linic
ian that the y are not approve d and he s u gge s ts an alte rnative
s trate gy. H owe ve r, whe n an alte rnative s trate gy is re c
om m e nd e d , the re is no follow-u pvisit with
the patient and the originatingc
linic
ian. T hu s , the patient re c
e ive s no e xplanation as to why the re
is ac
hange in plan. W e we re inform e d that m os t au thorizations arrive within one we e k from
W e xford c
e ntraloffic
e . Form os t c
ons u lts and proc
e d u re s , an appointm e nt is obtaine d within 30
d ays ;howe ve r, the re are e xc
e ptions whic
h take longe r. W e we re inform e d that at the c
olle gial
re view the re is s ignific
ant variation in re s pons e s bas e d on the phys ic
ian in P itts bu rgh who is
he aringthe pre s e ntations . W e we re inform e d that one orthos pine c
as e has be e n awaitingan
appointm e nt s inc
e Fe bru ary and ye t in Ju ne no appointm e nt has be e n arrange d . O ve rall, the re we re
proble m s withthe proc
e s s , partic
u larly withre gard to ins u ringappropriate follow u p. T his was
proble m atic be c
au s e c
ritic
al d oc
u m e nts that d e s c
ribe offs ite s e rvic
e s find ings and
re c
om m e nd ations we re c
om m only not available in the m e d ic
alre c
ord . T he re fore , follow u p is
m ore like ly to have be e n inc
om ple te ord e laye d .
ord s ofpatients s e nt offs ite forc
ons u lts . Five ofs ix c
ontaine d proble m s .
Patient #1
T his is a34-ye ar-old who had priorm u ltiple gu ns hot wou nd s to the abd om e n as we llas as thm a.
H e als o had ahistory ofhe m orrhoid s s inc
e 2009. H e was s e e n forhis he m orrhoid s fou rtim e s ove r
ape riod ofm onths be fore he was s e nt ou t fore m e rge nc
y m e d ic
alfu rlou gh. H e was
Ju ne 2014
M enard C orrec ti
onalC enter
P age 24
d iagnos e d at the tim e ofs e nd ou t withathrom bos e d he m orrhoid and was s c

he d u le d fors u rge ry.
W he n he was s e nt ou t, no e m e rge nc
y room re port from the hos pitalwas available in the m e d ic
al
re c
ord . T he re was abriefhand writte n note by aphys ic
ian. Su rge ry was s c
he d u le d bu t d e laye d a
fe w d ays d u e to an inability to pe rform the s u rge ry in an offic
e . T he ope rative re port is s tillnot
available . H e has re c
e ive d follow-u p by the prim ary c
are c
linic
ian althou ghthis c
linic
ian at the
tim e ofthe e nc
ou nte rlac
ke d the re qu ire d d oc
u m e nts ..
Patient #2
T his is a68-ye ar-old withas thm aand hype rte ns ion. O n 3/17/14, he was note d to have an e le vate d
pros tate s pe c
ificantige n and was re fe rre d to the u rology c
linic
. H e was s e e n the re on 4/8and a
re c
om m e nd ation was m ad e foratrans re c
talgu id e d biops y. T his was re fe rre d to c
olle gialre view
and was approve d . T he patient was the n s e e n bu t the re is no d isc
u s s ion re gard ingthe plan fora
biops y. T he re has be e n no follow u p re gard ingthe biops y and thou gh abone s c
an has be e n
ord e re d , the re has be e n no d isc
u s s ion withthe patient re gard ingthe bone s c
an. T he re was ad e lay
in re c
e ivingany re port from the offs ite s e rvic
e . T his patient ne e d s appropriate follow.
Patient #3
T his is a60-ye ar-old whos e proble m list c
ontains hype rte ns ion and aright ingu inalhe rnia. D e s pite
the fac
t that s inc
e be ingin prison he has had ahe art attac
k and the plac
e m e nt ofc
oronary s te nts in
his he art (and had re c
e ive d thre e s te nts in 2005), this inform ation is not on the proble m list. O n
1/22/14, he was s e nt ou t to c
ard iology afte rthe re qu e s t had be e n m ad e on 12/16/13. A t that tim e ,
ac
ard iacc
athe te rization was re c
om m e nd e d . T he c
ard iacc
athe te rization re port d e m ons trate d 100%
right c
oronary oc
c
lu s ion and the re was are c
om m e nd ation to optim ize m e d ic
alm anage m e nt. T he
patient retu rne d on 3/25and was s e e n by the phys ic
ian on 3/26. H e was s e e n thre e we e ks late ron
4/15and the re c
om m e nd ation was m ad e that he re tu rn in one to two we e ks . H e has not be e n s e e n
s inc
e . T he re is no d isc
u s s ion re gard ingthe find ings of100% oc
c
lu s ions to his right c
oronary. T his
patient ne e d s appropriate follow u p.
Patient #4
T his is a66-ye ar-old withhype rte ns ion, d iabe te s and ahistory ofapos itive T B s kin te s t. O n 4/1/14,
he was s c
he d u le d foran onc
ology visit d u e to apriord iagnos is ofpros tate c
anc
e rin 2011. H e had
be e n tre ate d , bothwithrad iation and horm onalthe rapy. T he horm onalthe rapy was d isc
ontinu e d
afte rthre e ye ars . T he re is an onc
ology note in the c
hart bu t it lac
ks any plan orre c
om m e nd ation.
T he patient was s e e n on retu rn by the phys ic
ian and re tu rne d to the c
e llhou s e forafollow u pin
s ix m onths . It is not c
le ar how the phys ician kne w that this was appropriate s inc
e the re is no
re c
om m e nd e d plan. T he patient was s u ppos e d to be s e e n two d ays late rby the nu rs e prac
titione r,
bu t this visit was c
anc
kd own. A fe w d ays late r, ac
he c
k ofhis blood pre s s u re was
als o c
anc
kd own. T he offs ite s e rvic
e note was not retrieve d u ntil5/16from a4/1
visit;it c
ontains no s u bje c
tive d ata, no obje c
tive d ata, no as s e s s m e nt and no plan. It is not c
le ar
how anyone knows what to d o ne xt withthis patient.
Patient #5
T his patient was s c
he d u le d for an ortho visit on 3/19/14. H e is a53-ye ar-old withhype rte ns ion.
H e has c
om plaine d ofhippain s inc
e agu ns hot wou nd to the hipm any ye ars ago. In D e c
e m be rhe
had an x-ray whic
hd e m ons trate d wors e ningofhis hipproble m withafe m oralhe ad c
ollaps e .
Ju ne 2014
M enard C orrec ti
onalC enter
P age 25
O n 3/19, he was s e nt foran ortho c

ons u lt, whic
hre c
om m e nd e d atotalhipre plac
e m e nt. T he re has
be e n no follow u pafte rthis visit withan e xplanation to the patient. O n 5/15, the M e d ic
alD ire c
tor
was s u ppos e d to have had ac
olle gialre view bu t this was c
anc
e lle d . O n 5/22, the c
olle gialre view
proc
e s s approve d the re fe rralbu t as ofthis d ate nothingfu rthe ris in the re c
ord . T his patient, with
ac
ollaps e of his fe m oral he ad viewe d in D e c
e m be r 2013 c
ontinu e s to await an appropriate
inte rve ntion.
N e xt, we re viewe d e ight c
as e s forpatients forwhom proc
e d u re s we re s c
he d u le d and in five ofthe
e ight the re we re s e riou s proble m s withpatients re c
e ivingthe s e rvic
e s the y ne e d e d .
Patient #6
T his is a31-ye ar-old who has ahistory ofapos itive T B s kin te s t bu t the proble m list d oe s not
d esc
ribe whe re he is at in the proc
e s s . H e was s c
he d u le d foraC T s c
an ofthe thorax on 4/24/14.
A c
he s t x-ray had re ve ale d ahilarm as s in the c
he s t. T he C T s c
an was pe rform e d on 4/24/14afte r
the ne e d forit was d e s c
ribe d on 2/26/14. T he re has be e n no c
linician follow u pwiththe patient,
e ve n thou ghthe C T s c
an re port d e s c
ribe s a3.5c
e ntim e te r hilar m as s orpos s ibly ad e nopathy in
the right infe riorhilu m . T he re are no note s on follow-u pothe rthan ac
olle gialre view, c
anc
e lle d
on 5/15d u e to the P itts bu rghphys ician not be ingavailable . T his c
as e ne e d s u rge nt follow-u p.
Patient #7
T his is a68-ye ar-old withirritable bowe ls ynd rom e and c
oronary artery d ise as e withs te nts plac
ed
in 2008. H e als o has GE R D and low bac
k pain. H e was s e nt forac
olonos c
opy on 4/25/14. H e has
had GI c
om plaints s inc
e 2013and it is re c
ord e d that his c
om ple te blood c
ou nt he m oglobin d roppe d
from 15.7to 12.1within le s s than aye ar. O n 3/14/14, this was d isc
u s s e d at c
olle gialre view in term s
of obtainingc
olonos c
opy. T his was s c
he d u le d for 4/25 and he re c
e ive d it. T he c
olonos c
opy
re ve ale d le ft-s ide d d ive rtic
u los is. M e anwhile , in Janu ary 2014his he m oglobin had d roppe d to 10.1,
s u gge s tingthat he had lost athird ofhis blood . H e was followe d u pon 6/16, bu t only be c
au s e he
c
om plaine d ofd izz ine s s . T he re c
om m e nd ation from GI that he re c
e ive ahighfibe rd iet was ne ve r
followe d u p. H e has ne ve rhad appropriate follow-u pafterthe c
olonos c
opy. H e ne e d s ac
om ple te
blood c
ou nt and aprim ary c
are c
linic
ian follow-u p.
Patient #8
T his is a44-ye ar-old withapos itive he patitis B te s t and c
irrhos is. O n 2/27/14, alive r s pe c
ialist
re c
om m e nd e d an e s ophagogas trod u od e nos c
opy and an u ltras ou nd for c
irrhos is. T he E GD was
c
om ple te d and it d e m ons trate d s e ve re re flu x d ise as e . H e was s e e n at the U nive rs ity ofIllinois for
he patitis B tre atm e nt and the y we re re lu c
tant to s tart m e d ic
ations be c
au s e he wou ld be re le as e d
s oon and the y wante d to ins u re that he wou ld be able to c
ontinu e tre atm e nt on the s tre et. D e s pite
the d isc
u s s ion withU ofI, the re has be e n no follow-u p. W e pre s s e d the iss u e and he d oe s have a
private phys ic
ian and the y ind ic
ate d to u s the y wou ld work on the arrange m e nts s o that the y c
ou ld
c
ontac
t U ofI, who c
ou ld initiate tre atm e nt and the n his c
ontinu ity u pon re le as e wou ld be c
om e
s e am le s s .
Patient #9
T his is a42-ye ar-old withc
oronary arte ry d ise as e , ahistory ofahe art attac
k, asthm a, d iabe te s and
hype rte ns ion. T his patient was s c
he d u le d foran M R I on 4/21/14. O n 2/19, the phys ic
ian s aw
Ju ne 2014
M enard C orrec ti
onalC enter
P age 26
him for low bac

k pain and ord e re d an M R I of his s pine . O n 4/21, the M R I was d one . H e had
alre ad y d e m ons trate d re ally s ignific
ant d e ge ne rative joint d ise as e of the s pine . T his patient has
had no follow u pre gard ingthe M R I and an approac
hto his proble m . T his patient re qu ire s follow
u pby the program .
Patient #10
T his is a 45-ye ar-old with a history of high blood pre s s u re who in Fe bru ary c
om plaine d of
d iffic
u lty s wallowing, inc
re as ingfor two ye ars . H is proble m is e s pe c
ially with s olid food s . O n
2/18/14, the d oc
torord e re d an u ppe rGI and this was s c
he d u le d for4/11/14. A s of5/22/14, the re
was no re port ye t from the hos pital. T he re has be e n no follow-u p visit with the patient and no
re port. T his partic
u larc
as e ne e d s follow u p.
Infirmary Care
ate d on the third floorofthe he althc
are u nit and c
an be ac
c
e s s e d by e le vatoror
as tairway. T he are ac
an ac
c
om m od ate 26 be d s and is c
onfigu re d as two fou r-be d room s , s e ve n
two-be d room s and two two-be d ne gative air-pre s s u re re s piratory isolation room s . T he two fou rbe d room s have no toile ts ors inks within the room s . T he infirm ary are ais d e s igne d in are c
tangle
withthe patient room s alongthe ou te rpe rim e te rand ac
e nterare ac
ontainingthe nu rs ingstation,
s u pply room , patient s howe rand s e parate c
le an and d irty u tility room s .
all s ys te m and patients are pad loc
ke d in the ir room s . P atients re qu iring
atte ntion wou ld have to ye llorpou nd on the irc
e lld oorto obtain as taffm e m be r
s atte ntion. In the
e ve nt the patient was u nc
ons c
iou s , he wou ld not be fou nd u ntile ithe r nu rs ingor s e c
u rity s taff
pe rform e d rou tine rou nd s ofthe are a. In the e ve nt ofan e nvironm e ntale m e rge nc
y, s u c
has afire ,
sec
u rity s taffwou ld ne e d to go to e ac
hroom to u nloc
k the pad loc
k in ord e rto e vac
u ate patients .
tion, the re we re 13patients and two patient c
are atte nd ants in
the infirm ary.
T he u nit is s taffe d withat le as t one re giste re d nu rs e 24hou rs ad ay, s e ve n d ays awe e k. Se c
u rity
s taffthat is as s igne d to the he althc
are u nit pe rform s rou tine rou nd s throu ghou t the infirm ary.
Inm ate porte rs pe rform allthe janitoriald u ties in the infirm ary bu t provide no m e d ic
alc
are . P orte rs
have re c
e ive d no trainingin blood -borne pathoge ns , infe c
tiou s and c
om m u nic
able d ise as e s , bod ily
flu id c
le an-u p, propers anitation ofinfirm ary room s , toile ts and s howe rs , be d s , fu rnitu re and line ns
and c
alinform ation.
A n infirm ary d aily logis m aintaine d whic
hlists the patient
s nam e and nu m be r, ad m iss ion d ate
and tim e , s tatu s, for e xam ple m e ntalhe alth or m e d ic
al, d iagnos is, d isc
harge d ate and tim e and
c
om m e nts .
E ac
hW e d ne s d ay, as agrou p, the M e d ic
alD ire c
tor, s taffphys ic
ians , infirm ary R N and s u pe rvising
R N re view e ac
hpatient
s m e d ic
alre c
ord and visit e ac
hpatient.
O fthe 26 be d s , only fou r are the trad itionalhos pital-s tyle be d . T he re m aind e r ofthe be d s are
approxim ate ly 18to 24inc
he s highand c
ons tru c
ted ofas te e lfram e withas olid bottom and
Ju ne 2014
M enard C orrec ti
onalC enter
P age 27
pe rm ane ntly attac

he d to the floor. O fthe fou rhos pital-s tyle be d s , only one has fu llle ngths id e
rails .
Infirm ary be d d ingand line ns we re ofpoorqu ality, in that m any we re torn and had ragge d e d ge s .
A d d itionally, infirm ary s taff re porte d line ns we re s hort in s u pply. D u ring the infirm ary
ins pe c
tion, it was le arne d that the infirm ary porte rs lau nd e rthe infirm ary be d d ingand line ns in a
re s id e ntials tyle was hingm ac
hine loc
ate d on the u nit. Sinc
e allinfirm ary be d d ingand line ns m u s t
be c
ons id e re d c
ontam inate d , it is d ou btfu lthe y are be ingad e qu ate ly s anitize d whe n was he d on
the u nit d u e to the wate r te m pe ratu re not be inghigh e nou gh. Staff was ins tru c
te d to have the
was hingm ac
hine wate r te m pe ratu re c
he c
ke d to as s u re at le as t 140 d e gre e s Fis be ingattaine d
d u ringthe was h c
yc
le . Staff was fu rthe r ins tru c
te d that in ord e r to prope rly s anitize be d d ing
line ns , the y ne e d to be was he d for am inim u m of25 m inu te s withlau nd ry d e te rge nt at awate r
te m pe ratu re of at le as t 160 d e gre e s F, or was he d for am inim u m of 10 m inu te s with lau nd ry
d e te rge nt and abe ginningble ac
hbathofat le as t 100ppm at awate rte m pe ratu re ofat le as t 140
d e gre e s F.
tion, the re we re five m e d ic
alpatients in the infirm ary. T hre e of
the patients we re c
las s ified as ac
u te c
are and two as board e rs rathe r than c
hronicc
are , with
d oc
u m e ntation m ore fre qu e ntly than re qu ire d by O ffic
e ofH e althSe rvic
e s polic
y and proc
e d u re .
A llfive re c
ord s c
ontaine d phys ic
ian and nu rs ingad m iss ion d oc
u m e ntation. A lld oc
u m e ntation
was in the Su bje c
tive -O bje c
tive -A s s e s s m e nt-P lan (SO A P )form at as re qu ire d by the D e partm e nt
ofC orre c
tions O ffic
e ofH e althSe rvic
ord e d
as ord e re d by the phys ic
ian forthe ac
u te c
y forthe
c
hronicc
are patients . M e d ic
ations we re d oc
u m e nte d on e ac
h patient s pe c
ificm e d ic
ation
ord . D e partm e nt of C orre c
tions O ffic
e s polic
y re qu ire s
infirm ary patients to be c
las s ified at the tim e ofad m iss ion as to the irm e d ic
alac
u ity le ve lby u s ing
the te rm s e ithe r ac
u te c
are or c
hronicc
are . T he fac
ility is inappropriate ly u s ingthe te rm
board e rins te ad ofc
hronicc
are .T he te rm board e ris ahou s ingd e s ignation whe re as the te rm
c
hronicc
are is am e d ic
alac
u ity d e s ignation. A d d itionally, in the SO A P d oc
u m e ntation form at,
the A re pre s e nts as s e s s m e nt.Forc
hronicc
are c
las s ified patients , phys ic
ians and nu rs ings taff
are inappropriate ly d oc
u m e ntingboard e r for the as s e s s m e nt. A gain, the te rm board e r is a
hou s ingd e s ignation and in no way d e s c
ribe s the patient
s m e d ic
alc
ond ition, whic
h s hou ld be
d oc
u m e nte d in the as s e s s m e nt.
Infection Control
A nam e d re giste re d nu rs e fu nc
tions as the fac
ility infe c
tion c
ontrolnu rs e (IC -R N )and has be e n in
1
the pos ition 3 /2 ye ars . W he n re qu ire d , s he inte rfac
e s withthe D e partm e nt ofC orre c
tions O ffic
e
of H e alth Se rvic
e s , C ou nty D e partm e nt of P u blicH e alth and the Illinois D e partm e nt of P u blic
H e alth (ID P H ). D aily, the ind ivid u alre views laboratory re ports and c
om ple te s and s u bm its to
ID P H allre portable c
u ltu re d and
tre ate d . P e r the infe c
tion c
ontrol nu rs e , the re is alow inc
id e nc
e of c
illin
re s istant Staphyloc
oc
c
tions .
T he IC -R N c
ond u c
tions in the d ietary d e partm e nt, allc
e ll
hou s e s and the he althc
are u nit and as s u re s pe rs onalprote c
tive e qu ipm e nt (P P E )is available in
Ju ne 2014
M enard C orrec ti
onalC enter
P age 28
all c
linic
al are as . A d d itionally, s he pe rform s pre -as s ignm e nt and annu al food hand le r
e xam inations for s taffand inm ate s to work in the d ietary d e partm e nt and m onitors tu be rc
u los is
sc
re e ningand te s tingforinm ate s , s taffand volu nte e rs , as we llas offe rs and m onitors H e patitis A
and B vac
c
ine to staff. T he IC -R N has traine d 11inm ate pe e re d u c
ators in H IV d ise as e , he patitis
C , s e xu ally trans m itte d infe c
tions , tu be rc
u los is and prope rhand was hing.
N e gative air-pre s s u re re ad ings in the two re s piratory isolation room s are m onitore d from gau ge s
loc
ate d in the infirm ary nu rs ings tation. In the e ve nt ofthe los s ofne gative airpre s s u re , the gau ge s
ind ic
ate s u c
h, bu t the re are no visu alor au d ible alarm s to im m e d iate ly bringto the atte ntion of
infirm ary s taff the los s of ne gative air pre s s u re . A tou r of the he alth c
are u nit, inc
lu d ingthe
infirm ary, ve rified pe rs onalprote c
tive e qu ipm e nt (P P E)available to s taffin allare as as ne e d e d .
tu re proofc
ontaine rs forthe
are u nit
om m e rc
m e d ic
om m u nic
annu ally.
T he u nit is c
le an withthe janitoriald u ties pe rform e d by inm ate porters . P orters have re c
e ive d no
trainingin blood -borne pathoge ns , infe c
tiou s d ise as e s , bod ily flu id c
le an-u p, prope rs anitation of
infirm ary room , be d s , fu rnitu re and line ns and c
alinform ation. H e althc
are
u nit porte rs lau nd e r infirm ary line ns in ahe althc
are u nit lau nd ry room u s ingare s id e ntials tyle
was hingm ac
hine . A te s t ofthe was hingm ac
hine hot wate rte m pe ratu re ind ic
ate d ate m pe ratu re of
only 125 d e gre e s F. T his te m pe ratu re is too low to as s u re the prope r c
le aningand s anitizingof
pote ntially bod ily flu id s oile d be d line ns . In ord e r to prope rly s anitize , line ns are to be was he d
u s inglau nd ry d e te rge nt in wate rat am inim u m te m pe ratu re of160d e gre e s Fforam inim u m of25
m inu te s or for am inim u m of10 m inu te s in wate r at am inim u m te m pe ratu re of140 d e gre e s F
u s inglau nd ry d e te rge nt and able ac
hbathhavingan initials tartingc
onc
e ntration of100parts pe r
m illion.
T he im pe rviou s vinylc
oatingon e xam ination s tools and table s and infirm ary m attre s s e s was note d
to be torn or c
rac
ke d , whic
h pre ve nts proper s anitizing and allows for pote ntial c
ros s c
ed .
A d d itionally, it was note d the re was no u s e ofpape r on e xam ination table s be twe e n patients in
e ithe r the c
e ll hou s e s or the he alth c
are u nit e xam ination room s , and the re was no polic
y or
proc
e d u re to m anu ally d isinfe c
t the table s be twe e n patients .
O ne c
e llhou s e s ic
kc
allroom d id not have as ink forwas hinghand s .
InmatesInterviews
T we lve ins u lin d e pe nd e nt inm ate s , s ix from Sou th hou s e and s ix from N orth 2, were rand om ly
c
hos e n and inte rviewe d . A ll 12 had be e n d iagnos e d s e ve ral ye ars pre viou s ly, and all we re
knowle d ge able re gard ing the ir c
hronicd ise as e . A ll 12 we re knowle d ge able re gard ing the
s ignific
anc
e of the ir he m oglobin A 1cblood le ve l and kne w the re s u lts of the ir m os t re c
e nt
he m oglobin A 1cblood le ve l. A llre ported be inge valu ate d by the phys ic
ian orP A e ve ry 3-4m onths
and havingthe ability to perform blood glu c
os e m onitoringpriorto the ad m inistration of
Ju ne 2014
M enard C orrec ti
onalC enter
P age 29
ins u lin. A llre porte d the y are inform e d of the ir m ost re c

e nt he m oglobin A 1cle ve ld u ringe ach
d iabe ticc
linic
. A llofthe inm ate s as s igne d to Sou thhou s e we re ofthe opinion that the fe m ale P A
was ve ry thorou ghin m anagingthe ird iabe ticc
are .
a.m . and 9:30 a.m . and d inne r is s e rve d be twe e n 3:30 p.m . and 5:00 p.m . It was re porte d that
m orningins u lin is ad m iniste re d be twe e n 2:00a.m . and 3:00a.m ., and afte rnoon ins u lin be twe e n
2:30p.m . to 3:30p.m .
A llthe
1.
2.
3.
4.
5.
inm ate s agre e d on the followingiss u e s :

C linic
s and blood work are fre qu e ntly c
anc
e lle d withno e xplanation.
D u ringc
linic
s , e ye s and fe e t are fre qu e ntly not e xam ine d .
T he re is as e riou s lac
ise tim e .
T he d iet is d iabe ticu nfriend ly.It is too highin c
arbohyd rate s and low in prote in.
In N orth2(s e gre gation), ins u lin is ad m iniste re d by he althc
are s taffthrou ghthe ope n front
c
e lld oorand nu rs ings taffd o not rotate inje c
tion s ite s . (T his is u nac
c
e ptable .)
6. A llre porte d u s ingthe irc
om m iss ary to m anage the ird iabe te s .
7. Som e tim e s the y re c
e ive ins u lin prior to e ating and s om e tim e s afte r e ating. (T his is
u nac
c
e ptable .)
8. E ve n thou ghhard c
arry
c
and y to s e lf-tre at low blood s u gar, s om e s e c
u rity s taffwilltake the c
and y d u ringrand om
s hake d owns . T he policy is not c
ons iste nt.
A llthe inm ate s we re ge ne rally in agre e m e nt that s ec

u rity offic
e rs are qu ic
k to re s pond to ad iabe tic
inm ate low blood s u gariss u e .
In re s pons e to qu e s tioningas to what two iss u e s , ifc
hange d , wou ld pos itive ly im pac
t the irability
to be tte r m anage the ir d ise as e , all12 im m e d iate ly ans we re d by voic
ingto im prove the d iet and
inc
re as e the am ou nt ofe xe rc
ise tim e .
A re view of11ofthe 12(one c
hart not available )d iabe ticpatient m e d ic
alre c
ord s ind ic
ate d the
following:
1. D iabe te s was note d on e ac
hproble m list.
2. T he O ffic
e ofH e althSe rvic
e s approve d , pre -printe d c
hronicc
linicform was u s e d at e ac
h
c
hronicc
linicvisit.
3. A ll11 patients we re e valu ate d in d iabe ticc
linice ve ry fou r m onths as re qu ire d by the
tions polic
y.
4. T hre e patients we re c
las s ified as be ingin good c
ontrol, s ix in fairc
ontroland two in
poorc
ontrol.
5. O fthe two patients c
las s ified as be ingin poorc
ontrol, the re was no d oc
u m e nte d plan to
he lp m ove the m into fairorgood c
ontroland the re was no inc
re as e in the fre qu e ncy
ofc
hronicc
linice valu ations .
6. In thre e of the 11 re c
ord s , the e xam ination was inc
om ple te , in that the re was no
d oc
u m e nte d c
om m e nt as to the pre s e nc
e , abs e nc
e orqu ality offoot pu ls e s orfoot s e ns ation.
T his om iss ion was s pe c
ificto one nu rs e prac
titione r.
7. A ll11patients we re re c
e ivingtwic
e ad ay A c
c
u C he c
ks priorto ins u lin ad m inistration.
Ju ne 2014
M enard C orrec ti
onalC enter
P age 30
Dental Program
Executive Summary
O n Ju ne 17-19, 2014, ac
om pre he ns ive re view ofthe d e ntalprogram at M e nard C C was c
om ple te d .
Five are as ofthe program we re ad d re s s e d inc
c
are ;2)
the qu ality ofc
y ofthe phys ic
al
fac
are ;and 5)the ove ralld e ntalprogram m anage m e nt.
T he re are thre e s e parate d e ntalc
linic
s at M e nard C C . A s ingle c
hairc
linicat N orth2, as ingle c
hair
c
linicat the R e c
e ivingand C las s ific
ation c
linic
, and afou r-c
hair c
linicloc
ate d in the H e alth
Se rvic
e U nit (H SU ). T he c
hairs /u nits at the H SU are only two ye ars old and in e xc
e lle nt re pair.
T he c
abine try is old , ru s tingand has s e ve ralare as ofc
hippingpaint. T he c
linic
s at N orth2and the
R ec
ation are s im ilarly old and worn. T he x-ray d e ve lope rs at N orth2and R & C
d o not work at all. T he y s hou ld be re plac
e d or re paire d im m e d iate ly. Ins tru m e ntation was
s u ffic
ient.
Staffingwas ad e qu ate to m e e t the d e ntalne e d s at M e nard C C .
are d e live ry was an are aofc
onc
e rn. N o c
om pre he ns ive e xam ination ortre atm e nt
plans we re d oc
u m e nte d pre c
e d ing the d e live ry of c
om pre he ns ive c
are . N o d oc
u m e nte d
e xam ination of the s oft tiss u e s nor pe riod ontal as s e s s m e nt was part of the e xam ination and
tre atm e nt proc
e s s . H ygiene c
are and prophylaxis we re not provid e d prior to re storations .
R e s torations proc
e e d e d withou t appropriate intra-oralrad iographs . O ralhygiene ins tru c
tions we re
ne ve rd oc
u m e nte d .
D e ntal e xtrac
tion proc
e d u re s we re provid e d in c
om plianc
e with the e le m e nts of the re view.
R ad iograph we re c
u rre nt and ad e qu ate , the re as on for the e xtrac
tion was d oc
u m e nte d , and a
c
ons e nt form was always c
om ple te d priorto orals u rge ry.
R e m ovable partiald e ntu re s s hou ld be c
ons tru c
e ofc
are d e live ry
inc
lu d e d in the c
om pre he ns ive c
are proc
e s s . A re c
ord re view re ve ale d that partial d e ntu re s
proc
om pre he ns ive e xam ination and tre atm e nt plan. A pe riod ontale xam and
as s e s s m e nt and pe riod ontalc
are was ne ve rprovide d . B e c
au s e the c
om pre he ns ive e xam ination and
tre atm e nt plans are abs e nt, it was im pos s ible to as c
e rtain ifallne c
e s s ary c
are was c
om ple te d prior
to fabric
Sic
kc
allis ac
c
e s s e d throu ghthe inm ate re qu e s t form or staff re fe rrals if the pe rc
e ive d ne e d is
im m e d iate . T he SO A P form at was u s e d and the patient
sc
om plaint ad d re s s e d . H owe ve r, tre atm e nt
s e ld om proc
e e d e d withaprope rd iagnos is.
A n inad e qu ate triage is ac
c
om plishe d throu gh the re qu e s t form . T he form s are e valu ate d and
inm ate s s c
he d u le d ac
c
ord ingly. U rge nt c
are ne e d s (pain and s we lling)are id e ntified from the form
and s e e n in five to te n d ays . T his s hou ld be d one within 24-48hou rs from the d ate ofthe re qu e s t.
T he re is no s ys te m in plac
e to provide atim e ly fac
e -to-fac
e e valu ation withm e d ic
al/d e ntals taff
forinm ate s withu rge nt c
are c
om plaints .
Ju ne 2014
M enard C orrec ti
onalC enter
P age 31
Inm ate s who re qu e s t rou tine c

are are s e e n and e valu ate d within 14 d ays . T he y are plac
e d on
waitinglists forrou tine c
are orc
le anings.
ord is not thorou ghand is poorly d e ve lope d . T he re is
no s ys te m in plac
alc
alc
ons u ltation
orinte rve ntion priorto d e ntaltre atm e nt.
as ke d , the c
linic
ian ind ic
T he s te rilization are ais rathe rlarge and s hare d withthe d e ntallaboratory. P rope rste rilization flow
was inte rru pte d by laboratory e qu ipm e nt. D isinfe c
tion proc
e d u re s we re ad e qu ate in allthe c
linic
s.
O fc
onc
e rn was the fac
t that the s te am au toc
lave s we re be ings pore te s te d only onc
e am onth.
P rofe s s ionalgu id e line s c
allforwe e kly te s ting. Im m e d iate c
orre c
tion is c
alle d for.
Safe ty glas s e s we re not worn by patients d u ringtre atm e nt. N o rad iation haz ard s igns we re pos te d
in the are as whe re x-rays are take n.
T he c
ontinu ingqu ality im prove m e nt program was inad e qu ate and poorly u tilize d . T he d e ntal
program s hou ld d e ve lops tu d ies and c
orre c
tive ac
ribe d in the
bod y ofthis re view.
T he M e nard C C P olicy and P roc
e d u re s M anu alford e ntalwas d ate d 1995withno ind ic
ation that
it had be e n u pd ate d . T his is an inad e qu ate d oc
u m e nt from whic
hto ru n the d e ntalprogram .
Faile d appointm e nt rate s approac
he d 40% . T his is ve ry high and m u s t be ad d re s s e d . Se c
u rity
pre c
e d e nc
e and u navailability ofe s c
ort s taffs hou ld be ad d re s s e d ad m inistrative ly.

M e nard C C has ad e ntals taffofthre e fu ll-tim e d e ntists , one d e ntalhygienist, and thre e fu ll-tim e
d e ntal as s istants . A ll are W e xford H e alth Se rvic
e s e m ploye e s e xc
e pt one of the d e ntists . In
ad d ition, one P R N d e ntist and thre e P R N as s istants are available if ne e d e d . T his m e e ts the
A d m inistrative D ire c
tive s taffinggu ide line s and s hou ld be ad e qu ate to provide m e aningfu ld e ntal
s e rvic
e s forM e nard
s 3700inm ate s .
A ll provid e rs have c
u rre nt c
re d e ntials on file and all the s taff are c
u rre nt with the ir C P R
c
e rtific
ation. T he s taffingis ad e qu ate to m e e t the ne e d s ofM e nard C C .
Recommendations: N one . M e nard is ad e qu ate ly s taffe d and allprivile ge s and c
re d e ntials are in
plac
e.

T he re are thre e s e parate d e ntalclinic
s at M e nard C C . A s ingle c
hairclinicis at N orth2and
Ju ne 2014
M enard C orrec ti
onalC enter
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s e rvic
e s the s e gre gation inm ate s and age ne ralpopu lation hou s e d in that u nit. A nothe rs ingle c
hair
u nit is in the R e c
ation c
linicand is u s e d for the s ou the rn Illinois re c
e ption
sc
re e ninge xam ination. It c
ontains apanore x x-ray and d e ve lope r. T he third is afou rc
hairc
linic
loc
ate d in the H e alth Se rvic
e U nit and s e rvic
e s the re s t of the ins titu tion. T he re is a400 be d
m e d iu m -s e c
u rity s ate llite ins titu tion, bu t it d oe s not have a d e ntal c
linic
. T his popu lation is
s e rvic
e d by the c
linicin the H e althSe rvic
e U nit.
T he c
hairs /u nits in the H SU c
linicare only two ye ars old and in e xc
e lle nt re pair. T he re is as ingle
x-ray u nit forthis e ntire c
linicand it is ve ry old , fad e d and worn. T he re is apanore x u nit on the
sec
ond floorofthis bu ild ing, above the d e ntalc
linic
. T he m e talc
abine try is old , ru s tingand has
s e ve ralare as ofc
hippingpaint. P rope rd isinfe c
tion is d iffic
u lt.
T he c
linicat N orth2is s im ilarly old and worn, as is the c
linicat R e c
ation.
A re alc
onc
e rn is that the x-ray d e ve lope rs in the N orth2c
linicand the R & C c
linicd o not work at
all. A llrad iographs ne e d to be brou ght bac
k to the H SU c
linicford e ve loping. T his is u nac
c
e ptable
in that x-rays are ofte n ne e d e d im m e d iate ly, e s pe c
ially as ad iagnos tictoolin u rge nt c
are s itu ations .
T he s e d e ve lope rs s hou ld be re plac
e d orre paire d im m e d iate ly. Ins tru m e ntation is ad e qu ate .
T he fou rc
hairs /u nits in the H SU are in ve ry s m allind ivid u als pac
e s . T his s pac
e is bare ly ad e qu ate .
T he s ingle c
hairc
linic
s at N orth2and R & C are s m allbu t ad e qu ate . T he laband s te rilization are a
is large . T he e xistingfac
ility is ad e qu ate to m e e t the ne e d s ofthe ins titu tion. T he x-ray d e ve lope rs
ne e d to be re plac
e d orre paire d im m e d iate ly.
Recommendations:
1. R e plac
e orre pairthe x-ray d e ve lope rs in the N orth2and R & C c
linic
s.

hniqu e s and proc
e d isinfe c
tion was
tants we re be ing
u s e d . P rote c
tive c
ove rs we re u tilize d on m os t u nit s u rfac
es.
A n e xam ination ofins tru m e nts in the c
abine ts and s torage are as re ve ale d that allwe re prope rly
bagge d and s te rilize d . A llhand piec
e d u re s the m s e lve s at the H e althSe rvic
e U nit c
linicwe re im prope r. Flow d id
not proc
e e d from d irty to c
le an. T he u ltras onicwas on the wrongs ide ofthe s ink and ad e ntallathe
and prote c
tive c
ove rs we re s itu ate d be twe e n the s ink and the au toc
lave .
T he R e c
ation c
linicu s e d d ispos able ins tru m e nts .
T he c
linicat N orth2 had aproper flow ofs te rilization from d irty to c
le an. Su rfac
e d isinfe c
tion
was ad e qu ate and prope rd isinfe c
tants we re in u s e . P rote c
tive c
ove rs we re e xte ns ive ly u s e d .
Ju ne 2014
M enard C orrec ti
onalC enter
P age 33
N o biohaz ard warnings igns we re poste d in the sterilization are as. Safe ty glas s e s we re not always
tion is always ne c
e s s ary, forpatient and provide r. I als o obs e rve d that
no warnings igns we re posted whe re x-rays we re be ingtake n to warn ofrad iation haz ard .

A re view of s pore te stinglogs re ve ale d that s pore te s tingof the s te am au toc
lave s was be ing
ac
c
om plishe d only onc
e am onth. T his is highly irre gu lar and violate s O SH A gu id e line s c
alling
forwe e kly s pore te s tingofau toc
lave s . T he d ry he at ste rilize ris te s te d on an irre gu lar, s om e what
qu arte rly bas is. T he s e are rathe r e gre giou s d e fic
ienc
ies that s hou ld be c
orre c
Ste am au toc
lave s and d ry he at s te rilize rs s hou ld be te s te d we e kly.
T he re we re no biohaz ard s igns in the s te rilization are a.
Recommendations:
1. D e ve lop as te rilization s ys te m that im ple m e nts aproper flow from d irty to ste rile . Spore
te st the au toc
lave s and s te rilize rs on awe e kly bas is and m aintain prope rlogs.
2. P rovid e s afe ty glas s e s to patients re c
e ivingd e ntalc
are .
3. P lac
e biohaz ard warnings igns in the s te rilization are as in the d e ntalc
linic
s.
4. P ost warnings igns in the are awhe re x-rays are be ingtake n to warn pre gnant fe m ale s of
pote ntialrad iation haz ard s .
Comprehensive Care
tive tre atm e nt c
are proc
eed
plan, to inc
lu d e all ne c
ord s re ve ale d that no
c
om pre he ns ive e xam ination was pe rform e d and no tre atm e nt plans d e ve lope d . N o e xam ination of
s oft tiss u e s or pe riod ontal as s e s s m e nt was part of the tre atm e nt proc
e s s . H ygiene c
are and
prophylaxis was ne ve r part of c
om pre he ns ive c
are . R e s torations we re , in five of the c
harts ,
provide d withou t appropriate d iagnos ticx-rays forc
aries . N o hygiene tre atm e nt was part ofany
of the rou tine c
are provide d . Fu rthe r, oralhygiene ins tru c
tions we re ne ve r d oc
u m e nte d in the
d e ntalre c
ord as part oftre atm e nt.
Recommendations:
1. C om pre he ns ive rou tine tre atm e nt be provide d only from a we ll d e ve lope d and
d oc
u m e nte d tre atm e nt plan.
lu d e ape riod ontalas s e s s m e nt and thorou gh e xam ination of all s oft
tiss u e s .
3. In allc
aries .
4. H ygiene and pe riod ontalc
ess.
5. T hat c
e s and d e ntal
prophylaxis.
u m e nte d .
Ju ne 2014
M enard C orrec ti
onalC enter
P age 34
Dental Screening
M e nard C C is the R e c
ation C e nte rforthe Sou the rn R e gion ofthe Illinois D O C .
A llre c
ord s re viewe d re ve ale d that the e xam was pe rform e d in atim e ly m anne r, apanoram icxray was take n, and the A P H A c
ate gorization was c
om ple te d . I d id not obs e rve the s c
re e ning
proc
e s s bu t it was d e m ons trate d to m e and I fou nd it proc
e d u rally ad e qu ate . Fou rofthe panoram ic
x-rays we re proc
e s s e d im prope rly and pre s e nte d as an opaqu e ne gative . T he s e rad iographs are not
ac
c
e ptable for d iagnos ticu s e . T his proble m d id not oc
c
u r in late rre c
ord re views . I was told the
d e ve lope r in the re c
e ption c
linicwas not fu nc
tioningprope rly. T he rad iographs we re be ing
d e ve lope d in the m ain c
linic
.
Recommendations:
1. Ins u re that the e qu i
pm e nt failu re that is c
au s ingthe rad iographproble m is ad d re s s e d and
re pairc
om ple te d A SA P .
Extractions
A re view of10re c
ord s ofinm ate s who had d e ntale xtrac
tions re ve ale d that nine ofthe 10we re in
fu llc
om plianc
e withthe as pe c
ts re viewe d . T he rad iographwas ove rthre e ye ars old in one ofthe
re c
ord s and the re as on fore xtrac
tion was not inc
lu d e d in anothe r. T his d oe s not rise to ale ve lof
c
onc
e rn. A qu ic
k sc
an ofs e ve ralothe rre c
ord s ofinm ate s who had te e the xtrac
te d d id not re ve ala
re pe at ofthe s e iss u e s . In two ofthe re c
ord s , non-re s torable was provide d as ad iagnos is forpain.
T his proble m was s e e n in othe rre c
ord s re viewe d in othe rare as .
Recommendations:
1. T hat prope rd i
agnos is be part ofthe tre atm e nt proc
ess.
s s hou ld proc
e e d only afte rallothe rtre atm e nt re c
ord e d on
ad d re s s e d firs t. In none ofthe re c
om pre he ns ive e xam ination and tre atm e nt
plan d e ve lope d prior to im pre s s ions for re m ovable partiald e ntu re s . In none we re oralhygiene
c
are ororalhygiene ins tru c
tions provid e d . P e riod ontalas s e s s m e nt and tre atm e nt was not provid e d
in any ofthe re c
ord s . B e c
au s e the re was no c
om pre he ns ive e xam ination norany tre atm e nt plans
d e ve lope d , it was im pos s ible to as c
e rtain if allne c
e s s ary c
are , inc
lu d ingope rative and /or oral
s u rge ry tre atm e nt, was c
Recommendations:
1. A c
inc
e e d all
c
are , inc
s.
e s s and that the
c
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onalC enter
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Dental Sick Call

Sic
kc
allis ac
c
e s s e d viathe inm ate re qu e s t form or from s taff re fe rralif the pe rc
e ive d ne e d is
im m e d iate . It take s five to te n d ays for u rge nt c
are c
om plaints to be s e e n. T his is u nac
c
e ptable .
T he y s hou ld be s e e n within 24-48hou rs .
In all10re c
ord s re viewe d the SO A P form at was u s e d and the patient
s c
om plaint was ad d re s s e d .
T he re view s howe d that the s ic
kc
allappointm e nt was not be ingu s e d forrou tine c
are . Tre atm e nt
proc
e e d e d withad iagnos is in only two c
as e s and an im prope rd iagnos is in anothe r. T his lac
k ofa
properd iagnos is was s e e n in re c
ord s re viewe d in othe rare as that inc
lu d e d s ic
kc
alle ntries .
Recommendations:
1. T hat alltre atm e nt proc
e e d s from aprope rd iagnos is.
2. T hat inm ate s withu rge nt c
are ne e d s are s e e n with24-48hou rs .
Treatment Provision
A n inad e qu ate triage s ys te m is in plac
e that prioritize s tre atm e nt ne e d s . Inm ate re qu e s t form s are
e valu ate d by the d e ntalprogram by the followingd ay and the irtre atm e nt ne e d s , bas e d u pon the
re qu e s t form , are prioritize d . U rge nt c
are ne e d s are ide ntified from the re qu e s t form and s e e n
A SA P , ofte n takingfive to te n d ays . O the rs are s c
he d u le d ac
c
ord ingly orplac
e d on the hygiene
list ifre qu e s te d . A llre qu e s t form s are s e e n within 14d ays .
Inm ate s s e e k u rge nt c
are via the inm ate re qu e s t form or, if the y fe e l the y ne e d to be s e e n
ontac
tingM e nard C C s taff, who c
an the n c
allthe d e ntalc
s
c
om plaint. T he s e inm ate s are s e e n at the d e ntists d isc
re tion. Inm ate s withu rge nt c
are c
om plaints
(pain ors we lling)from the re qu e s t form ofte n take five to te n d ays to be s e e n. T he y s hou ld be s e e n
with24-48hou rs from the d ate ofthe re qu e s t. M id -le ve lprac
titione rs at the u nits d o not rou tine ly
s e e the inm ate fac
e -to-fac
are ne e d s as ind ic
ate d on the re qu e s t form . Ifan
inm ate c
om plains ofatoothac
he , s we lling, orpain to the nu rs e m akingrou nd s , the nu rs e c
an c
all
the d e ntalc
linicwiththis inform ation. T he y c
an provide ove r-the -c
ation. Som e
inm ate s are s e e n im m e d iate ly ifc
orre c
tionals taffc
an ge t the inm ate ove rto the d e ntalc
linic
. T he re
is no s ys te m in plac
e to provide afac
e -to-fac
e e valu ation withm e d ic
al/d e ntals taffforinm ate s that
c
om plain ofpain or s we lling. T his s hou ld be provid e d within 24-48 hou rs from the d ate ofthe
re qu e s t.
R e qu e s t form s from inm ate s s e e kingrou tine c
are are e valu ate d the ne xt workingd ay and the
inm ate give n an appointm e nt to be e valu ate d within 14d ays . Inm ate s re qu e s tingto have the irte e th
c
le ane d are plac
e d on awaitinglist. Inm ate s for rou tine c
are are plac
e d on awaitinglist in
s e qu e ntialord e r. T his list is approxim ate ly nine m onths long.
Recommendations:
1. A s ys te m s hou ld be im ple m e nte d im m e d iate ly that ins u re s that inm ate s with u rge nt c
are
c
om plaints (pain and s we lling)are s e e n and e valu ate d by m e d ic
al/d e ntals taffwithin 2448
hou rs from the d ate on the re qu e s t form . It is from this fac
e -to-fac
e e valu ation that
sc
he d u lingand tre atm e nt s hou ld proc
e e d . T he appropriate m e d ic
als taffin the u nits s hou ld
be u tilize d in this e ffort.
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M enard C orrec ti
onalC enter
P age 36
T he M e nard C C O rientation M anu alis m inim ally bu t ad e qu ate ly d e ve lope d for d e ntals e rvic
es
and ad d re s s e s type s ofc
are , ac
c
e s s to c
are and how tre atm e nt is s c
he d u le d .
Recommendation: N one

A n inte rview with the M e nard C C D e ntalD ire c
tor re ve ale d that he was not aware of a
polic
y and proc
e d u ralm anu al. A re view ofthe M e nard C C P olic
y and P roc
e d u re s M anu al
re ve ale d alarge s e c
tion d e vote d to the polic
ies and proc
e d u re s ford e ntalc
are . It was d ate d
1995 withno ind ic
ation that it has be e n u pd ate d s inc
e that tim e . T his is not an ad e qu ate
d oc
u m e nt from whic
hto ru n the d e ntalprogram .
Recommendations:
1. T hat the d e ntalprogram at M e nard C C d e ve lop ac
u rre nt, d etaile d , thorou ghand ac
c
u rate
polic
y and proc
e d u re m anu althat d e fine s how allas pe c
ts ofthe d e ntalprogram are to be
ru n and m anage d . O nc
e d e ve lope d , it s hou ld be re viewe d and u pd ate d on are gu lar bas is
and as ne e d e d forne w polic
ies and proc
e d u re s .
Failed Appointments
T he faile d appointm e nt rate of abou t 40% is ve ry high. I was told the re as ons for m iss e d
appointm e nts inc
lu d e d re fu s al, faile d , loc
kd own, and othe r.W he n as ke d , the d e ntists re late d that
othe ru s u ally m e ant s e c
u rity pre c
e d e nc
e s and u navailability ofe s c
ort staff. T he pe rc
e ntage was
ve ry high for the m onth of A prilwhe n 362 appointm e nts we re m iss e d be c
au s e of aloc
kd own.
W he n only faile d appointm e nts (inm ate c
hos e not to c
om e to appointm e nt) are inc
lu d e d , the
pe rc
e ntage d rops to abou t 12%. In an old e r high-s e c
u rity ins titu tion withm u ltiple m iss ions and
sec
u rity c
onc
e rns s u c
h as M e nard C C , m ove m e nt of inm ate s is are alc
halle nge . T hat d oe s not
e xc
u s e the proble m . E ve ry e ffort s hou ld be m ad e to work with ad m inistrative and c
orre c
tional
s taffto c
orre c
t this iss u e .
Recommendations:
1. D e ve lop an aggre s s ive C Q I s tu d y to e valu ate re as ons for m iss e d appointm e nts and
pe rs iste ntly s e e k re m e d ies to c
orre c
t the proble m and im prove ge ttinginm ate s to the ir
appointm e nts .

A re view of the d e ntalre c
ord s of the fou r inm ate s on antic
oagu lant the rapy re ve ale d that two
re c
ord s m ad e no m e ntion ofthis in the he althhistory s e c
tion ofthe d e ntalc
hart. It was ind ic
ate d
bu t not re d flagge d in the othe rtwo. N o tre atm e nt was provide d to any ofthe s e inm ate s .
linic
ians ind ic
Ju ne 2014
M enard C orrec ti
onalC enter
P age 37
Recommendations:
alhistory s e c
al
c
ialpre c
atc
ofthe provide r
e s pe c
alproc
e d u re.
Specialists
A loc
alO ralSu rge on, D r. Jay Swans on, is available and u s e d fororals u rge ry proc
e d u re s to inc
lu d e
trau m a, re m ovalofd iffic
u lt wisd om te e thand e valu ation and re m ovaloforalpathology. H e has
offic
e s in E ffingham and M t. V e rnon, Illinois. Ge ne ralane s the s iac
as e s u s e the E ffingham offic
e.
A ll re c
ord s re viewe d re ve ale d prope r c
as e s e le c
tion and good patient m anage m e nt, and good
re c
ord d oc
u m e ntation.
Dental CQI
s to the C Q I c
om m itte e . T he d e ntal
program c
ond u c
te d two stu d ies , one in 2013and anothe rin 2014. O ne involve d the e ffe c
ts ofthe
m e d ic
ations D ilantin and N orvas con the inc
id e nc
e ofgingivalhype rplas ia. T he othe rwas as tu d y
ofgrievanc
e s as re late d to the d iffe re nt c
e llhou s e s within the ins titu tion. T he re s u lts ofe ac
hwas
pre s e nte d and s te ps take n to ad d re s s the find ings.
N o stu d ies we re in plac
e to ad d re s s program we akne s s e s and proble m are as .
Recommendations:
1. D e ve lopvigorou s C Q I s tu d ies that ad d re s s the we akne s s e s pre s e nte d in this re port and pu t
in plac
e s te ps to c
orre c
t the proble m s .
Mortality Review
From Janu ary 1, 2013, to the d ate of ou r visit, the re we re 12 d e aths at M e nard , inc
lu d ingone
hangingand two m u rd e rs . O fthe re m ainingnine c
as e s , we c
hos e s ix forre view he re . In thre e of
the c
as e s , we ide ntified s e riou s laps e s in c
are that like ly c
ontribu te d to the tim ingofthe patients
d e m ise . In afou rthc
as e , apatient withd e te rioratingne u rologics tatu s was not worke d u pforc
au s e s
ofhis d e c
line .
Patient #1
T his was a63-ye ar-old m an who e nte re d ID O C in 2007 and d ied on 2/11/14 of c
om plic
ations
followings e ve ralc
ard iacarre s ts . H e had no known c
ard iacrisk fac
tors u pon intake . H e was fou nd
to have hype rte ns ion in 2011, bu t blood pre s s u re c
he c
ks we re d isc
ontinu e d by the M D withfollow
u pas ne e d e d . H e was not starte d on m e d ic
ation. Like wise , he had an u nfavorable
Ju ne 2014
M enard C orrec ti
onalC enter
P age 38
lipid profile at that tim e bu t this was not tre ate d e ithe r. H is Fram ingham at this tim e was qu ite
high, at 25% .
In Se pte m be r 2013, he pre s e nte d with c
he s t pain, s hortne s s of bre ath and hype rte ns ion (blood
pre s s u re 180/120, 190/120). H e was give n ad ose of c
lonid ine and plac
e d in the infirm ary for
obs e rvation. T he ad m ittingnu rs e obtaine d ahistory oforthopne a. T he pre viou s M e d ic
alD ire c
tor
s aw the patient that m orningand note d that he had no c
om plaints bu t the patient was tac
hyc
ard ic
withahe art rate of130. N o E C G was ord e re d . In fac
t, no othe rwork-u portre atm e nt was provide d
and his s ym ptom s grad u ally re s olve d . H e was d isc
harge d to his c
e llthat afte rnoon withno s pe c
ific
follow u pord e re d .
O n 1/17/14, he pre s e nte d withorthopne a. H is blood pre s s u re was 140/78, pu ls e 104. T he nu rs e d id
athorou ghe valu ation and e lic
ite d the history ofare c
e nt d e athin the fam ily. She d e s c
ribe d him as
anxiou s , and re fe rre d him to M D line and m e ntalhe alth.
O n 1/21, he pre s e nte d with c
ou gh, c
he s t pain, s hortne s s of bre ath, d iarrhe a and abd om inal
c
ram ping. B lood pre s s u re was 150/98, pu ls e 88. H e was re fe rre d to the d oc
torand s e e n that d ay.
T he d oc
tor note d that he re porte d bilate ral c
he s t pain whe n lying s u pine . H e appe are d
appre he ns ive . She d e c
id e d he had bronc
hitis vs pne u m oniaand gas troe nte ritis. She ord e re d ac
he s t
x-ray and antibioticand afollow-u pappointm e nt in one we e k. T he c
he s t x-ray s u gge s te d aright
lowe r lobe infiltrate , m ild c
ard iom e galy, and a s m all le ft ple u ral e ffu s ion. T he follow-u p
appointm e nt on 1/28was c
anc
e lle d .
O n 1/31, the d oc
tors aw the patient forongoings hortne s s ofbre ath. B lood pre s s u re was 124/100,
pu ls e 108. H is lu ngs we re d e s c
ribe d as c
le ar, and no pe d ale d e m awas e vid e nt. She c
onc
lu d e d
pne u m onia, ru le ou t C H F,and ord ere d anothe rc
he s t x-ray, E C G, B N P and ad m itte d him to the
infirm ary for23-hou robs e rvation. She retre ate d him withthe s am e c
ou rs e ofantibioticthat he ju s t
c
om ple te d , the n late rs e nt him to the loc
alE D afte rc
onfe rringwiththe M e d ic
alD ire c
tor. H e was
ad m itte d withC H Fand s u bs e qu e ntly s u ffe re d s e ve ralc
ard iacarre sts and u ltim ate ly d ied .
Opinion:It is not appropriate to tre at ahype rte ns ive u rge ncy in aprison infirm ary;the patient
s hou ld have be e n s e nt to the ou ts id e E D bac
k in Se pte m be rwhe n he initially pre s e nte d withthe s e
s ym ptom s . It is like ly that his c
ard iacc
ond ition wou ld have be e n re c
ognize d the n and appropriate
tre atm e nt c
ou ld have be e n initiate d , the re by s u bs tantially d e c
re as inghis risk ofd e ath.
Patient #2
T his was a62-ye ar-old m an who was ad m itte d to ID O C in 2008 and d ied on 11/16/13 of GI
ble e d ingfrom ru ptu re d e s ophage alvaric
e s d u e to c
irrhos is. H e had ahistory ofd e c
om pe ns ate d
c
irrhos is and priorGI ble e d ingin 2007.
H e pre s e nte d to the form e r M e d ic
al D ire c
tor on 11/13/13 with s e ve re le thargy, d izz ine s s ,
d ys pne a, m e le nax 2d ays .H e was tac
hyc
ard icwithahe art rate of104, blood pre s s u re was 124/74
and had gros s ly pos itive s tools on e xam . T he d oc
torord e re d labs and plac
e d him in the infirm ary
at 1:10p.m . A t 1:30p.m ., the ad m ittingR N d e s c
ribe d him as pale and pas tie (s ic
). H e
Ju ne 2014
M enard C orrec ti
onalC enter
P age 39
had as m allblac
k s tool. H e c
om plaine d ofm ild abd om inaland c
he s t pain. H is blood pre s s u re was
112/70and he art rate was 100. H is H bwas 10.2g/d L, d own from 13.3in Ju ly.
A t 4:00pm , his blood pre s s u re was 110/62, pu ls e 80and he was d e s c
ribe d as we ak and tire d .
A t 8:00p.m ., astat C B C was d rawn pe rthe d oc
tor
s ord e r. It was re s u lte d at 9:13p.m . and was
7.6g/d L. A t 9:45p.m ., the nu rs e c
alle d the d oc
torre gard ingthe s e re s u lts and he ord ere d only IV
flu id s .
O n 11/14, at 3:25a.m ., his blood pre s s u re was 100/60, pu ls e 104. A t 9:20a.m ., the d oc
tors aw the
patient, who re porte d we akne s s , d izz ine s s and ongoingm e lanotics tool. H e s e nt the patient to the
loc
alhos pital, whe re he d ied two d ays late r.
Opinion:T o plac
e apatient withknown e nd s tage live rd ise as e and ac
tive GI ble e d ingin aprison
infirm ary is be yond inappropriate ;in this c
as e it m ay have ac
c
e le rate d his d e m ise . E ve n whe n
m as s ive blood los s was e vid e nt by the d ram aticd ropin he m oglobin, the d oc
torfaile d to inte rve ne
appropriate ly u ntilit was too late .
Patient #3
T his was a 66-ye ar-old m an with m u ltiple m e d ic
al proble m s inc
lu d ingd iabe te s , C O P D and
c
oronary arte ry d ise as e with history of5 ve s s e lC A B G in 2009, who was re c
e ive d in ID O C in
2006 and d ied on 4/7/13ofm e tas taticre nalc
e llc
arc
inom a. H e firs t pre s e nte d on 11/12/12with
d iffic
u lty bre athing, e s pe c
ially whe n lyingd own. H e was re fe rre d to the M e d ic
alD ire c
tor, D r.
She aring, and s e e n the ne xt d ay. D r. She aringord e re d ac
he s t x-ray and E C G and ad m itte d the
patient to the infirm ary for aC H Fe xac
e rbation and tre ate d him withd iure tic
s . T he c
he s t x-ray
was pe rform e d on 11/13/12and d id s how pu lm onary vas c
u larc
onge s tion. It als o s howe d nod u lar
d e ns ities within the lu ngs bilate rally of whic
h find ings are s u s pic
iou s for ne oplas tic
-m e tas tatic
d ise as e ,afind ingwhic
he s c
ape d the atte ntion ofthe d oc
torwhe n he re viewe d the film on the d ate
it was take n. T he patient was d isc
harge d bac
k to his c
e llon 11/15/12.
T he film was re ad on 11/15and re c
e ive d by the ins titu tion on 11/26, at whic
htim e the s am e d oc
tor
s igne d the re port and m arke d it file (rathe rthan pu llc
hartors e e patient).
O n 11/30, the d oc
tor s aw the patient in follow u p of his infirm ary ad m iss ion, note d that his
s ym ptom s we re im prove d , bu t d id not re view the x-ray re s u lt with the patient or m ake any
re fe re nc
e to it.
O n 12/10, the patient again pre s e nte d withs hortne s s ofbre athand c
he s t tightne s s and was re fe rre d
to the M e d ic
alD ire c
tor, who s aw him that d ay. T he d oc
tornote d that the patient
s s ym ptom s we re
now re s olve d .H e c
onc
lu d e d , C H F, m u ltiple m e d ic
alproble m s ,m ad e no c
hange s and re tu rne d
the patient to his c
e ll.
O n 1/16/13, the patient was brou ght to the H C U viawhe e lc
hair with c
om plaints of c
he s t pain
rad iatingd own his le ft arm and s hortne s s of bre ath. H e was hype rte ns ive and d iaphoretic
. T he
nu rs e got ave rbalord e rto s e nd the patient to the ED , whe re he was fou nd to have m e tas taticre nal
c
e llc
anc
e r. H e u ltim ate ly opte d forpalliative c
are and e xpire d thre e m onths late r.
Ju ne 2014
M enard C orrec ti
onalC enter
P age 40
Opinion:T hat the d oc

torove rlooke d the pu lm onary nod u le s on his own re ad ingofthe c
he s t x-ray
is s u rprisingbu t not inc
onc
e ivable . T hat he the n ignore d the m whe n he re viewe d the finalre port
is, in ou ropinion, ne glige nt.
Patient #4
T his was a64-ye ar-old m an who was s e ve re ly be ate n by his c
e llie on 1/24/13and ad m itte d to the
trau m a s e rvic
e at B arne s Je wish M e d ic
al C e nte r with intrave ntric
u lar he m orrhage s , s u bd u ral
he m orrhage s , airway c
om prom ise and m as s ive inju ries to the fac
e and ne c
k. H e was s tabilize d and
re tu rne d to the ins titu tion on 1/31/13. O ve rthe e ns u ingthre e we e ks , the patient was d e s c
ribe d with
inc
re as ingd isd ain as be ingu nc
ooperative and u nwillingto partic
ipate in s e lf-c
are . H is be havior
be c
am e inc
re as ingly proble m atic
, in that he u ltim ate ly be gan s m e aringfe c
e s in his room , d isrobing
and u rinatingon him s e lf. H e was d iagnos e d withps yc
hos is s e c
ond ary to he ad inju ry and s tarte d
on ps yc
hotropic
s . H e d e ve lope d d iffic
u lty s wallowingand le t m e d ic
ation and liqu id s s pillou t of
his m ou th. H e c
ontinu e d to re c
e ive his u s u alm e d ic
ations , inc
lu d ingorald iabe te s m e d ic
ations .
T he re was no re c
ord ofhis blood glu c
os e be ingc
he c
ke d .
O n 2/25/13, he was note d to be ve ry s e d ate d and s low to re s pond . H is blood pre s s u re was 78/40
and blood glu c
os e was 54. T he d oc
tors aw the patient at 7:50a.m . and d e s c
ribe d him as le thargic
and non-ve rbal;he had afle xion re s pons e to pain. H e ord e re d IV flu id s and m onitoringofvital
s igns . A t 9:30a.m ., the blood pre s s u re im prove d to 110/50. T he re are no fu rthe rm e as u re m e nts of
blood glu c
os e . A t 10:45a.m ., he c
od e d and d ied .
T he au tops y re port liste d the finalc
au s e ofd e athas blu nt trau m ato he ad aggravatinghype rte ns ive
and arte rios c
le roticc
ard iovas c
u lard ise as e and d iabe te s m e llitu s .
Opinion:T his patient was c
le arly c
halle ngingto c
are for. H owe ve r, in the fac
e ofhis d e c
lining
ne u rologicc
ond ition, work-u ps hou ld have be e n pu rs u e d .

W e re viewe d s e ts of m inu te s from D e c
e m be r, Fe bru ary and M arc
h and als o looke d at am ore
re c
e nt s e t d rafte d by the ne w Q I C oord inator, the he ad ofthe m e d ic
alre c
ord s program . T he Q I
program at M e nard C orre c
tionalC e nte rc
le arly atte m pts to c
om ply withthe polic
y re qu ire m e nts
and as s u c
hthe re is d oc
u m e ntation ofm u c
hac
tivity. T he proble m is that the re is not are lations hip
be twe e n that ac
tivity and im prove m e nts in the qu ality ofs e rvic
e s provid e d . A n e xam ple follows .
T he re is are qu ire m e nt that nu rs ingpe rform anc
e on protoc
ols be re viewe d . T wo ofthe ite m s that
are re viewe d are, is the re ac
hiefc
om plaint d e s c
ribe d and is the re ad u ration liste d forthat c
hief
c
om plaint.A c
c
ord ingto thos e two ite m s , the pe rform anc
e by the nu rs ingstaffc
olle c
tive ly is we ll
ove r 90%. T he proble m is that thos e two ite m s alone d o not c
om e c
los e to the re qu ire m e nts to
c
om ple te an ad e qu ate s u bje c
tive history. A s an e xam ple , ac
ou ghforam onthas the only history
writte n wou ld re s u lt in an as s e s s m e nt ofc
om plianc
e withthe re qu ire m e nt. O n the othe rhand , an
ad e qu ate history wou ld re qu ire , was the re afe ve r, was the re s hortne s s of bre ath, was there any
blood c
ou ghe d u p, was the c
ou ghprod u c
tive , were the re any othe rre late d s ym ptom s . A llofthe s e
qu e stions are c
ritic
alto d eterm iningthe natu re ofthe patient
s proble m .
Ju ne 2014
M enard C orrec ti
onalC enter
P age 41
So althou ghM e nard d oe s c

om ply withthe le tte rofthe polic
y re qu ire m e nts , the polic
y re qu ire m e nts
and trainingd o not ge t the s taffto the point whe re the y are as s istingthe program in im provingthe
qu ality ofc
are .
A nothe rite m is whe the rpatients s e nt foras c
e are s e e n on re tu rn within five
d ays . T his is re porte d as 100% . T he proble m is that u nle s s the re le vant pape rwork is available and
the re is ad isc
u s s ion be twe e n the phys ic
ian and the patient re gard ingthe find ings on that pape rwork
and the re c
om m e nd e d plan, the qu ality of c
are m ay s till be s u bs tand ard e ve n thou gh the
pe rform anc
e m ay be at 100% . T he s e are the kind s ofiss u e s whic
hd o ne e d to be ad d re s s e d s o that
the qu ality im prove m e nt program c
an be as ou rc
e forim provingthe qu ality ofc
are . In othe rare as ,
the re is d atac
olle c
tion whic
hm ay d e m ons trate inad e qu ate pe rform anc
e bu t the re is no analys is of
the c
au s e s or c
ontribu ting fac
tors to the inad e qu ate pe rform anc
e and the re fore the re is no
u nd e rs tand ingof what wou ld re as onably be the m os t e ffe c
tive im prove m e nt strate gy and s o
m onitoringc
ontinu e s ind e pe nd e nt ofim prove m e nt.
Ju ne 2014
M enard C orrec ti
onalC enter
P age 42
Recommendations
1. P lac
e apriority on fillingthe D ire c
torofN u rs ingand Su pe rvisingN u rs e pos itions .
1. C om ple te the re novations to the E as t c
e llhou s e s ic
kc
allare aand be gin re novations to the
re m ainingc
e llhou s e s ic
kc
allare as as s oon as poss ible .
2. Im m e d iate ly be gin u s inga pape r barrier whic
hc
an be c
hange d be twe e n patients on
e xam ination table s ord e ve lopaproc
e d u re to s anitize be twe e n patients .
3. U ntilre novate d , appropriate ly e qu ipc
e llhou s e s ic
kc
allare as and im m e d iate ly provid e for
hand s anitizingbe twe e n patients in the Sou thLowe rs ic
kc
allare a.
Reception:
1. T he qu ality im prove m e nt program m u s t u tilize ac
linician to re view the re c
ord s ofpatients
who have re c
e ntly gone throu ghthe re c
e ption proc
e s s and for whom abnorm alities have
be e n id e ntified in ord e r to ins u re that appropriate follow u p oc
c
u rs . T his s hou ld be an
ongoingpart ofthe qu ality im prove m e nt program .
Nursing Sick Call:
1. T rans ition to an allR e giste re d N u rs e triage and s ic
kc
alls ys te m . Lic
e ns e d P rac
tic
alN u rs ing
(LP N )staffis triagings ic
kc
allre qu e s ts and m ay orm ay not pe rform an e xam ination, m ake
an as s e s s m e nt and , the n, form u late aplan whic
hc
ou ld be no tre atm e nt ortre atm e nt from
approve d tre atm e nt protoc
ols orto re fe rto aprovid e r. A llofthe s e ac
tions are be yond the
ed u c
ope ofprac
tic
e foran LP N .
1. P hys ic
ians s hou ld be traine d and c
e rtified in aprim ary c
are field . O nly prim ary c
are traine d
provide rs s hou ld be m anagingc
hronicd ise as e s .
2. T he c
hronicd ise as e d atabas e s hou ld be u s e d as atoolto ide ntify are as in whic
hthe program
is u nd e rpe rform ings o that inte rve ntions c
an be targe te d to im prove c
are .
3. P rovid e rs s hou ld be im ple m e ntingac
hange to the c
are plan whe n patients have s u boptim al
c
ontrolofthe ird ise as e (s ).
4. A llprovid e rs ne e d ac
c
e s s to e le c
tronicre fe re nc
are .
5. T he re we re iss u e s withthe ac
c
u rac
y ofe valu atingthe d e gre e ofd ise as e c
ontrolforpatients
e nrolle d in the pu lm onary c
linic
. T his is at le as t partly d u e to the langu age ofthe polic
y,
whic
hs hou ld be re vise d to be m ore c
ons iste nt withthe N H LB I gu ide line s .
6. P rovid e rs s hou ld be fam iliar with alte rnative m e thod s of T B te s ting, i.e ., the inte rfe ron
gam m aas s ays , and the ir appropriate u s e . E fforts s hou ld be m ad e to c
onfirm patients
re ports ofpre viou s tre atm e nt forLT B I priorto c
om m ittingthe m to tre atm e nt.
7. T he c
e llbloc
kc
linic
s s hou ld be ad e qu ate ly e qu ippe d and pre s e nt aprofe s s ionalc
linic
al
e nvironm e nt. Safe ty c
onc
e rns am ongthe provide rs ne e d to be ad d re s s e d .
Ju ne 2014
M enard C orrec ti
onalC enter
P age 43
1. A c
linic
ally traine d s taffpe rs on s hou ld be re s pons ible forins u ringthat allre le vant offs ite
s e rvic
e re ports are available forthe c
linic
ian to review withthe patient within awe e k of
the offs ite s e rvic
e havingbe e n provide d .
2. W he n the s c
e re ports are available , the phys ician m u s t d oc
u m e nt a
visit withthe patient in whic
hthe find ings and plan are d isc
u ssed .
3. Se rvic
e s that c
annot be s c
he d u le d form ore than am onthm u s t be ad d re s s e d by the M e d ic
al
D ire c
torwiththe State M e d ic
alD ire c
tor.
1. N u rs ings taffm u s t be retraine d withre gard to an appropriate as s e s s m e nt forapatient who
has be e n s e nt to the hos pitaland re tu rne d to the infirm ary. Spe c
ific
ally, the trainings hou ld
inc
lu d e what s u bje c
tive and obje c
tive inform ation to c
olle c
t in re lations hipto the proble m s
that we re ad d re s s e d at the hos pital
2. A c
linic
ally traine d pe rs on s hou ld ins u re that allofthe re le vant offs ite s e rvic
e re ports for
u ns c
e s are available within a fe w d ays , inc
lu d ing d isc
harge
s u m m aries , e m e rge nc
y room re ports , ope rative re ports and c
athe te rization re ports s o that
the y c
an be d isc
u s s e d by the prim ary c
are c
linic
ian withthe patient and aplan c
an als o be
d isc
u ssed .
3. W he n aproc
e d u re oravisit is inte rru pte d d u e to aloc
kd own, the M e d ic
alD ire c
tors hou ld
be notified and he m u s t d e term ine whe the r, d e s pite the loc
kd own, it m u s t oc
c
u rorc
an it
wait u ntilthe ne xt d ay and oc
c
u rthe followingd ay.
Infirmary Care:
1. E s tablishanu rs e c
alls ys te m .
2. A d d re s s life /safe ty c
onc
e rns withinfirm ary patients pad loc
ke d in the irroom s .
3. T rain inm ate he alth c
are u nit porte rs in blood -borne pathoge ns , infe c
tiou s and
c
om m u nic
able d ise as e s , bod ily flu id c
le an-u p, the prope r c
le aning and s anitation of
infirm ary room s , be d s , fu rnitu re and line ns and c
alinform ation.
4. R e plac
e torn and ragge d line ns . M aintain an ad e qu ate s u pply ofbe d d ingand line ns .
5. Sanitize infirm ary be d d ingand line ns throu ghappropriate lau nd e ringm e thod s .
6. P rope rly d oc
u m e nt in the patient m e d ic
alre c
ord am e d ic
alac
u ity le ve li.e ., ac
u te , c
hronic
,
hou s ing, ad m inistrative plac
e m e nt.
7. P rope rly d oc
u m e nt in the patient m e d ic
alre c
ord am e d ic
alas s e s s m e nt rathe rthan ahou s ing
d e s ignation in the as s e s s m e ntportion ofan infirm ary patient SO A P note .
Infection Control:
1. C ontinu e to aggre s s ive ly m onitors kin infe c
tions and boils .
2. A s s u re aprac
tic
e ofappropriate ly lau nd e ringand s anitizinginfirm ary be d d ingand line ns
e ithe r in the he althc
are u nit orins titu tionallau nd ry. Iflau nd e ringin the he althc
are u nit,
wate rte m pe ratu re s s hou ld be m onitore d and re c
ord e d d aily to as s u re a160d e gre e or140
d e gre e re ad ing.
3. T rain allhe althc
are u nit porte rs in blood -borne pathoge ns , infe c
tiou s and c
om m u nic
able
d ise as e s and the prope rc
le aningand s anitizingofinfirm ary room s , be d s , fu rnitu re , toile ts
and s howe rs .
4. Sinc
e the re are no visu alorau d ible alarm s forthe infirm ary ne gative pre s s u re re s piratory
isolation room s , whe n apatient is isolate d d u e to res piratory infe c
tion, gau ge re ad ings
Ju ne 2014
M enard C orrec ti
onalC enter
P age 44
s hou ld be m onitore d and re c

ord e d e ac
hs hift. W he n the room s are e m pty orbe ingu s e d
forpu rpos e s othe rthan re s piratory infe c
tion, gau ge re ad ings s hou ld be m onitore d and
re c
ord e d we e kly.
5. Ins tall, at am inim u m , an au d ible alarm to im m e d iate ly notify infirm ary s taffofthe los s
ofne gative pre s s u re in re s piratory isolation room s .
6. C ritic
ally m onitorc
e llhou s e s ic
kc
allare as forc
le anline s s , the u s e ofapape rbarrier
be twe e n patients on e xam ination table s oras s u re table tops are s anitize d be twe e n patients
and appropriate hand was hing/sanitizingis oc
c
7. E ac
hm onth, c
ritic
ally ins pe c
t u phols te re d e qu ipm e nt and m attre s s e s forany te ars or
hole s in the ou te rc
ove rand as s u re the ite m s are take n ou t ofs e rvic
e u ntilre paire d .
Quality Improvement Program:
1. T he Q I polic
y and the trainingc
onne c
te d to it m u s t be re d one in ord e rto fac
ilitate qu ality
im prove m e nt e ffe c
tive ly oc
c
u rringat e ac
hins titu tion. T his wille ntailale ngthy
d isc
u s s ion.
Ju ne 2014
M enard C orrec ti
onalC enter
P age 45

Reception Process:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Chronic Care:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
P atient #11
P atient #12
P atient #13
P atient #14
P atient #15
P atient #16
P atient #17
P atient #18
P atient #19
P atient #20
P atient #21
P atient #22
P atient #23
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Patient Number
Ju ne 2014
Name
M enard C orrec ti
onalC enter
Inmate ID
P age 46
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Mortality Review:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
Ju ne 2014
Name
[redacted]
[redacted]
[redacted]
[redacted]
M enard C orrec ti
onalC enter
Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
P age 47
APPENDIX B
M o rtality R e vie ws
The taxonomy used for the mortality reviews is described in detail in Appendix 1. It outlines 14
distinct types of lapses in care, with each lapse representing a serious deviation from the standard
of care. Many cases had more than one lapse in care, and these are specified by number in the
case descriptions. We chose to use this methodology which was developed by the California
Prison Receivership because it has been certified by the Federal Court in Plata v. Brown, a case
involving adequacy of medical care in the California Department of Corrections and
Rehabilitation.
There were 127 deaths within IDOC between January 1, 2013 and June 1, 2014, 10 of which
were violent deaths (suicides or homicides) and were therefore not reviewed for the purposes of
this report. Of the remaining 117 mortalities, we reviewed 61 cases (52%) plus an additional 2
deaths from 2010; 63 cases total. The details of each case are described below. There were one
or more significant lapses in care in 38 cases (60%). This is an unacceptably high rate of
deviations from the standard of care. Of those cases with significant lapses, 34 (89%) had more
than 1 lapse.
C as e s with Laps e s in C are

Dixon Correctional Center
Patient 2
The patient was a 56-year-old man with asthma and a seizure disorder who died of metastatic
prostate cancer on 3/21/14. There were significant lapses in care. Of special note is the fact that
there is no documentation that the patient was seen from 9/20/13, when he was seen for chronic
care of his asthma and seizure disorder, until 1/13/14, when he was seen for a complaint of back
pain.
1. The patients PSA was 37.8 on 5/6/13. He did not see an urologist until 1/15/14. This is a
Type 3 lapse in care.
2. The patient had a history of chronic low back pain. On 1/13/14, he began complaining of
increasing back pain following a fall. He was seen by providers on 1/20/14 and 1/29/14 and
they noted that the patient was complaining of back pain. They did not address his pain.
This is of special concern, since the patient was being evaluated for prostate cancer and his
back pain may have related to metastatic disease. He subsequently was diagnosed with
metastases to the spine when he was admitted to the hospital on 2/3/14. These are Type 1
lapses in care.
3. The patient was housed in the infirmary following his prostate biopsy on 1/30/14.
Beginning on 2/2/14, at 12:05 a.m., he began complaining of fevers and not feeling well.
Over the next two days, he had temperatures of up to 104 degrees as well as tachycardia
with a pulse as high as 132. Despite being notified by the nurses of these findings, a
physician did not evaluate him until 2/3/14 at 5:00 p.m. and he was not sent to the
1
emergency room until 11:15 p.m. He was subsequently diagnosed and treated for sepsis.
These are Type 1 lapses in care.
4. The patients asthma and seizure disorder were not well controlled. He did not receive
timely or adequate care for these problems. These are Type 2 lapses in care.
Patient 4
The patient was a 51-year-old man with a history of diabetes, hypertension and HIV disease who
died of a cardiac arrest on 1/8/13. There were significant deviations from the standard of care.
1. The patient arrived at Dixon on 9/25/12 from STA-NRC. He saw a physician on 10/12/12
for his baseline diabetes and hypertension evaluations. The physician did not document any
history related to the patients diabetes and an inadequate history related to his
hypertension. A physician did not see him again for these problems. These are Type 2 lapses
in care.
2. The patient had a positive HIV test on 10/3/12. He did not see a physician for this until
12/10/12. The physician noted that the patients CD4 count was 116. He did not order
pneumocystis prophylaxis, which is indicated for a CD4 count < 200. These are Type 4
lapses in care.
3. The patient began refusing his insulin and other medications on 1/1/13. He was not referred
to a provider for counseling. This is a Type 3 lapse in care.
Patient 6
The patient was a 57-year-old man who died of metastatic lung cancer on 1/11/13. There were
significant deviations from the standard of care.
1. On two occasions (12/11/12 and 12/26/12), the patient did not receive dexamethasone as
ordered prior to his chemotherapy. These are Type 9 lapses in care.
Patient 7
The patient was a 78-year-old man with end stage liver disease and cardiac disease who died on
8/27/13. There were significant deviations from the standard of care.
1. A physician saw the patient on 9/12/12 for increasing ascites. The physician ordered
medication and follow-up in 10 days or sooner. The patient was not seen until 10/15/12,
when he was seen by a PA because he was complaining of shortness of breath when lying
down and that his medication had run out. The PA re-ordered the medication and an urgent
referral for a therapeutic paracentesis. This did not occur until 11/1/12 when the patient was
sent to the hospital for an emergency paracentesis. He was admitted for treatment of
progressive ascites and abdominal pain. He was discharged on 11/5/12 with a
recommendation for follow-up in liver clinic on 11/28/12. He was not seen in liver clinic
until 1/15/13. He had another paracentesis on that date. On 2/11/12, the patient had another
paracentesis. The interventional radiologist recommend a repeat paracentesis in 3-4 weeks.
The patient did not return until 4/12/12. These are Type 3 lapses in care.
2
2. On 2/11/13, the interventional radiologist recommended placement of a shunt to manage

the patients recurrent ascites. The request was approved at Dixon on 2/28/13. The
interventional radiologist did not evaluate the patient for the shunt until 5/10/13. The
interventional radiologist recommended clearance by cardiology and a liver consult prior
to the procedure. Neither of these consults had occurred as of 7/3/13, when the patient was
sent to the emergency room for vomiting. It does not appear that the patient returned to
Dixon prior to his death. (There are no notes in the medical record after 7/3/13.) These are
Type 3 lapses in care.
Patient 8
The patient was a 79-year-old man who died of metastatic prostate cancer on 6/20/13. There were
1. On 4/26/13, the patient had signed an advanced directive stating that he did not want CPR
for a full cardiopulmonary arrest but that he did want attempted resuscitation if his
breathing became labored and his heart was still beating. On 6/17/13, the patient was
admitted to the infirmary for increasing shortness of breath. The physician ordered a chest
x-ray and blood tests. The chest x-ray revealed bilateral pleural effusions with a focal
density. The physician, however, only stated that the x-ray showed an infiltrate. The
patients white blood cell count was normal. The physicians assessment was that the
patient had pneumonia. The physician ordered intravenous antibiotics. A physician did not
see the patient on 6/19/13. On 6/20/13 (no time on note), a physician documented that the
patient had been unresponsive since that morning. There is no documentation of any further
evaluation of the patient by a physician. At 7:15 a.m., a nurse documented that the patients
oxygen saturation was 63% with agonal breathing. The nurse documented that she informed
the physician, who did not issue any new orders. The patients oxygen saturation was 37%
at 7:45 a.m. and 45% at 8:30 a.m. There are no further notes in the patients medical record
until 1:13 p.m., when he was pronounced dead. This is a Type 3 lapse in care. If the patient
had been sent to the emergency room, his respiratory distress could have been more fully
evaluated and treated. If this had occurred, it is possible that he would have survived this
event.
2. The patient was receiving chemotherapy. The patient saw the oncologist on 8/29/12. The
oncologist ordered follow-up in four weeks. The patient did not return until 12/5/12. On
2/19/13, the oncologist ordered follow-up in one month. The patient did not return until
4/10/13. These are Type 3 lapses in care.
3. A nurse saw the patient on 2/28/13 because he was complaining that he hurt all over and
had chills. The nurse consulted with a physician who ordered pain medication, blood tests,
and follow-up in the morning. The patient was not seen for follow-up of these complaints.
This is a Type 3 lapse in care.
4. The patient was receiving warfarin for a history of deep vein thrombosis/pulmonary
embolus. His anticoagulation was not being managed appropriately. His INR was
subtherapeutic from 11/30/12 to 4/3/13, when a physician inappropriately stopped it. This
was never addressed. This is a Type 2 lapse in care.
5. Providers saw the patient for chronic care on 9/25/12, 1/28/13, and 5/30/13. The providers
did not document a history related to any of his chronic problems. These are Type 2 lapses
in care.
Patient 9
The patient was a 71-year-old man with a history of hypertension who died on 5/27/14. A nurse
evaluated the patient on 5/24/14 for nausea and vomiting. The nurse admitted the patient to the
infirmary for observation. It was a weekend and he was not seen by a physician. According to
nursing notes, he was stable. On 5/25/14, he became unresponsive and was sent to the hospital.
There are no further notes in the medical record. The cause of death is not documented. There were
1. The patient was seen in chronic care for hypertension on 7/30/12, 11/15/12, 1/13/13, 8/7/13,
11/12/13, and 4/18/14. A provider did not document a history at any of these visits.
Patient 10
The patient was a 73-year-old man with a history of Parkinsons dementia, anticoagulation for a
deep vein thrombosis, dysphagia requiring a gastric feeding tube and COPD, who died on 5/3/14
from a respiratory arrest. He had been housed in the infirmary for a long time. There were
1. His warfarin therapy was not appropriately managed. His INR was subtherapeutic on
1/30/14. The physician increased his warfarin and ordered a repeat test in one week. It was
not done until 3/19/14 and was still subtherapeutic. A physician reviewed the result on
3/20/14, but did not take any action. These are Type 2 lapses in care.
Patient 11
The patient was a 69-year-old man with hypertension, coronary artery disease, atrial fibrillation,
congestive heart failure, pulmonary hypertension, leukemia, and hyperlipidemia and brain cancer.
He died on 3/23/14. There were significant deviations from the standard of care.
1. As noted above, the patient had a multitude of medical problems. He was seen for chronic
care on 3/7/13. The physician did not document a history related to any of his problems.
On 5/13/13, the patient was diagnosed with brain cancer for which he underwent surgery.
He returned to Dixon on 5/23/13 and was admitted to the infirmary. He was discharged
from the infirmary on 5/24/13. Following his discharge, the patient was seen on numerous
occasions by a physician to follow-up specialty consultations. At these visits, the physician
reviewed the consultants recommendations with the patient but did not address the
patients other medical problems. A physician did not see the patient for chronic care until
12/18/13. At that time, the physician did not document a history related to any of the
patients problems. These are Type 2 lapses in care.
Patient 12
The patient was a 64-year-old man who died of metastatic penile cancer on 12/17/13. He had been
housed in the infirmary for a long time. There were significant deviations from the standard of
care.
1. From 9/28/13 to 11/25/13, the patient was admitted to an outside hospital on four occasions.
Over this period of time, the physician in the infirmary rarely evaluated him. The patient
was not even evaluated following his return after his admissions. Due to the poor
documentation in the medical record, it is not clear whether any of these hospitalizations
could have been prevented. These are Type 2 lapses in care.
Patient 14
The patient was a 70-year-old man with diabetes, asthma, hyperlipidemia, rheumatoid arthritis and
extensive metastatic disease from probable pancreatic cancer who died on or about 3/14/14. (He
was sent to the hospital on 3/14/14 and never returned to the facility). There were significant
deviations from the standard of care.
1. The patient had been steadily losing weight for approximately two years. This had not been
noted or evaluated. In addition, the patient was anemic. On 12/9/13, the nurse noted that he
was complaining of weakness and inability to walk. The nurse gave the patient a permit for
a wheelchair and referred him to a physician. On 12/14/13, the patient fell and hit his head.
The nurse who evaluated him noted that the patient had been referred to see a physician but
that the MDs lines are behind. On 12/16/13, an NP saw the patient. The NP noted that the
patient reported that he had been getting dizzy and falling and was very weak. The NP noted
that the patient was lethargic but did not examine him. The NP further noted that the patient
had had a 30-pound weight loss since December 2012 and was anemic. The NP ordered a
nutritional supplement and a wheelchair for the patient. The NP did not order any laboratory
tests or follow-up. On 12/24/13, a physician saw the patient to discuss denial of a referral to
a rheumatologist. The physician did not address the patients other problems other than to
order laboratory tests to assess the patients anemia. The physician ordered follow-up in 710 days. An NP saw the patient on 12/29/13 and noted that he was complaining of shortness
of breath, vomiting and constant pain that had been going on for months. The NP advised
the patient to wait until his appointment the following day and to take Tylenol and a muscle
relaxant, and to rest. A physician saw the patient on 12/30/13. The physician noted that the
patient had lost six pounds in two weeks. The physician also noted that the patient was
complaining of extreme pain from his rheumatoid arthritis. The physician ordered Ultram
for the pain (the patient had been ordered Ultram in the past and had been discontinued
because it did not work) and follow-up in three weeks. The physician also continued the
nutritional supplement. On 1/7/14, a NP saw the patient for complaints of weakness,
shortness of breath and difficulty keeping food down. The NP ordered medication for the
patients gastrointestinal symptoms and admitted him to the infirmary for observation. On
1/10/14, a physician evaluated the patient and requested a G.I. evaluation for nausea, weight
loss, and diarrhea. On 2/7/14, the patient had a colonoscopy that revealed an extrinsic mass
compressing the colon. On 2/24/14, he had a CT scan which revealed extensive
metastatic disease of possible pancreatic origin. The delays in evaluating the patients
weight loss and anemia are Type 15
6 lapses in care.
2. The patient was not receiving timely or adequate chronic care for his diabetes, asthma, and
rheumatoid arthritis. In 2013, he was only seen two times in chronic care clinic. The
physician did not document any history related to the patients problems on either of those
occasions. In addition, the patients hemoglobin A1c increased from 6.6% to 7.6%. The
physician attributed this to prednisone use but did not follow-up. These are Type 2 lapses
in care.
3. The patient had severe rheumatoid arthritis for which he was receiving Enbrel and
methotrexate. He had not seen a rheumatologist in over four years. On 10/24/13, a physician
had referred him to a rheumatologist. This request was subsequently denied. When
informed of the denial, the patient stated that he needed to see a rheumatologist because he
was wasting away, adding that the worst part is pain. On 12/30/13, a physician noted
that the patient stated that he was in such extreme pain he could not sleep. The physician
ordered Ultram, which, as noted above, the patient had received in the past and had been
ineffective. The failure to refer the patient to a rheumatologist is a Type 3 lapse in care.
Patient 16
The patient was a 67-year-old man with COPD, atrial fibrillation, hypertension, and prostate
cancer, who died on 2/28/13 from tuberculosis pneumonia and meningitis, Pneumocystis
pneumonia, and varicella encephalitis. There were significant deviations from the standard of care.
1. On 1/24/13, the patient was admitted to the hospital for progressive shortness of breath and
confusion. He returned to Dixon on 1/27/13. Beginning on 2/1/13, the patient became
increasingly short of breath, lethargic, weak, and confused, incontinent, and had
intermittent fevers. On 2/5/13, the patients temperature was 102 (axillary). The physician
did not document a history or physical examination. Despite the fact that the patient did not
have evidence of influenza, the physician ordered Tamiflu. On 2/6/13, the patients urine
culture was positive and the physician ordered IV antibiotics. On 2/7/13, the infirmary
physician began documenting that the patient had an extremely poor prognosis. On
2/11/13, he documented that the patient was possibly septic. On 2/12/13, the physician
finally sent the patient to the local hospital. He was admitted to the ICU for respiratory
failure. His condition continued to deteriorate and the next morning he was intubated. On
2/17/13, he was transferred to the University of Illinois Medical Center, where he died on
2/28/13. The failure to evaluate the patient when he had a fever is a Type 1 lapse in care.
The delays in sending the patient to the emergency room for evaluation as his condition
noticeably deteriorated are Type 3 lapses in care.
2. The patient arrived at STA-NRC on 8/12/12. It was noted that he had had an increased PSA
level of 8.5 ng/ml and been diagnosed with stage 1 prostate cancer at the county jail. The
patient was transferred to Dixon on 9/7/12 and housed in the infirmary due to his need for
oxygen for his COPD. The infirmary physician documented the patients history
of prostate cancer. His plan was to order a repeat PSA level in one month. The PSA was
repeated on 10/19/12 and was again 8.5 ng/ml. The lab was not reviewed until 11/21/12.
At that time, the Medical Director wrote a note that the test should be repeated in February
2013. The patient was never referred to an urologist for follow-up of his prostate cancer.
The failure to do so is a Type 3 lapse in care.
Patient 17
The patient was a 64-year-old man with COPD who died of metastatic rectal cancer on 4/30/13.
There were significant deviations from the standard of care.
1. The patient was being followed in chronic care for his COPD. The physicians did not
document a history related to his COPD at any of his chronic care visits. These are Type 2
lapses in care.
Patient 18
The patient was a 56-year-old man with diabetes, hypertension, chronic kidney disease, metastatic
pancreatic cancer and history of a stroke who died of a myocardial infarction on 10/15/13. There
were significant deviations from the standard of care.
1. On 10/14/13, at 6:30 p.m., a nurse evaluated the patient because he stated that he had not
been feeling well that day. The nurse noted that the patient was lethargic with irregular
respirations and a low oxygen saturation of 85-87%. The patients blood pressure was
140/80 mmHg. The nurse telephoned the physician on duty, who gave an order for the
patient to be placed in the infirmary with oxygen. At 7:42 p.m., the nurse noted that the
patient was lethargic and weak with a blood pressure of 80/60 mmHg. At 12:10 a.m., a
nurse noted that the patient vomited and that his blood pressure was 90/60. The nurse did
not contact the physician on either of these occasions. A nurse practitioner evaluated the
patient the next morning and sent him to the emergency room for evaluation of acute
respiratory distress. At the hospital, he was diagnosed with an acute myocardial infarction,
pneumonia, congestive failure and cardiogenic vs. septic shock. The physicians failure to
arrange for an evaluation of the patient when the nurse contacted him is a Type 1 delay.
Given the patients presentation, the physician needed to evaluate the patient or send him
to the emergency room for an evaluation. The failures of the nurse to contact a physician
when the patients blood pressure was so low are Type 3 lapses in care.
2. The patient was being followed in chronic care. The physicians did not document a history
related to his medical problems. These are Type 2 lapses in care.
Patient 19
The patient was a 75-year-old man with coronary artery disease, diabetes, hypertension,
hyperlipidemia and a history of multiple strokes who died on 1/4/13 of a likely myocardial
infarction/arrhythmia. There were significant deviations from the standard of care.
1. The patient was admitted to the infirmary on 12/7/12 for increasing need of assistance with
his ADLs. On 12/8/12, at 6:00 p.m., nurses noted that he was verbally nonresponsive. Nurses attempted to contact the physician on duty at approximately 6:30 p.m.
There is a note from an RN that she7
8 spoke to the physician at 9:30 p.m. The
physician gave orders to observe the patient for changes and report if there were any. The
nurse contacted the physician at 1:35 a.m. on 12/8/12 and notified him that the patient was
hypertensive and had a low grade fever. The physician gave an order to transfer the patient
to the hospital. The patient was subsequently diagnosed with an acute stroke. The delay in
sending the patient to the hospital is a Type 3 lapse in care.
related to his medical problems. These are Type 2 lapses in care.
Patient 21
The patient was a 76-year-old man with asthma/COPD and metastatic lung cancer who died on
5/10/13. There were significant deviations from the standard of care.
related to his chronic medical problems. These are Type 2 lapses in care.
Big Muddy River Correctional Center

Patient 24
The patient was a 66-year-old paraplegic man with a history of hypertension, asthma, recurrent
urinary tract infections, prior sepsis and bilateral above-the-knee amputations due to gangrene, who
died of sepsis and multi-organ failure on 5/22/13. He had been housed in the infirmary for a long
time. The medical records from the hospital where the patient was sent on 5/19/13 were not
available. There were significant deviations from the standard of care.
1. The patient began complaining of intermittent chest pain on 5/18/13 at 9:55 a.m. and again
at 12:50 p.m. A nurse evaluated him and provided appropriate care. At 6:00 p.m., a nurse
noted that he was complaining of being cold and of stomach, back and chest pain. The nurse
noted that the patient was lying in bed shaking. The nurse contacted the physician on duty
via telephone. The physician ordered an EKG, laboratory tests, two different antibiotics and
Tylenol for pain. On 5/19/13, at 2:00 a.m., a nurse noted that the patient stated, I need to
go to the hospital. The nurse further noted that the patient was yelling that he was in pain
and wanted to go out. The nurse documented that the patients hands and arms were cold,
that he was exhibiting some confusion, and that she was unable to obtain either a manual
or automated blood pressure. The nurse contacted the physician on duty. The nursed
documented that there were no new orders. At 4:00 a.m., the nurse noted that he/she had
contacted the laboratory multiple times and had not been able to obtain laboratory results.
At 8:30 a.m., the nurse noted that the patient stated he was sick. The nurse noted that the
patients respiratory rate was elevated (29/minute) and that he/she was unable to obtain a
blood pressure, palpate a pulse, or obtain an oxygen saturation. The nurse contacted the
physician, who advised her to send the patient to the hospital via ambulance. The patient
left the facility at 9:40 a.m. The
delays in sending the patient to the emergency room for needed care are Type 3 lapses in
care.
Patient 25
The patient was a 69-year-old man with a history of hypertension, hyperlipidemia, gout and dietcontrolled diabetes who died on 9/20/13 from ischemic and hypertensive heart disease. There was
a significant deviation from the standard of care.
1. On 9/20/13, nurses responded to a code 3 emergency call. Upon arrival, they found the
patient blue in color with no signs of respiration and no pulse detected. The nurses
initiated CPR. Custody staff had not initiated CPR. If CPR had been initiated in a timelier
manner, the patients death may have been prevented. The failure of the custody staff to
initiate CPR is a Type 14 lapse in care.
Patient 28
The patient was a 73-year-old man with a history of hypertension who died on 9/14/13 from a
cardiac arrest due to an acute myocardial infarction.
1. On 9/14/13, nurses responded to a Code 3 emergency in the patients housing area. The
patient was lying in his bunk, non-responsive and without pulse or signs of breathing.
Custody staff had not initiated CPR. If CPR had been initiated in a timelier manner, the
patients death may have been prevented. The failure of the custody staff to initiate CPR is
a Type 14 lapse in care.
Lincoln Correctional Center

Patient 31
The patient was a 57-year-old man with diabetes, hypertension, coronary artery disease with bypass
surgery on two occasions and hyperlipidemia who died from a cardiac arrest on 12/17/13. There
1. On 8/28/13, a nurse responded to a Code 3 call in the dining room. The patient was
complaining of crushing chest pain (10 on a scale of 10) and numbness in his left arm. The
nurse contacted a physician, who ordered an EKG and observation. The EKG did not reveal
any acute changes and the physician scheduled the patient to be seen the next morning. A
physician evaluated the patient the next morning, ordered medications and ordered a
cardiology consult for evaluation of five episodes of exertional chest pain with numbness in
the left arm. The Medical Director subsequently denied the referral. On 10/12/13, the patient
was seen for chronic care. The physician did not document a history related to chest pain.
On 11/11/13, the patient had a syncopal event that was attributed to low blood sugar (his
blood sugar was 27). The patient was treated and monitored in the infirmary overnight. The
following morning the physician discharged the patient from the infirmary and noted that he
also has chest pain. The physician did not obtain any further history related to the chest
pain. He ordered an EKG as soon as possible. The EKG did not reveal any acute changes.
The physician did not order any follow-up related
9
to the patients chest pain. From that time until the time of his death, the patient was not
evaluated by a physician. Given the patients cardiac history, complaints of chest pain
needed to be fully evaluated. The patient should have been sent to an emergency room for
further evaluation on 8/28/13 and the patient should have been referred to a cardiologist for
evaluation of his chest pain. Furthermore, there was no follow-up related to the patients
chest pain by the physicians at the facility even when the patient had another episode. These
are Type I lapses in care.
2. Custody staff did not initiate CPR. If CPR had been initiated in a timelier manner, the
patients death may have been prevented. This is a Type 14 lapse in care.
3. The patient did not receive timely or appropriate care for his diabetes. These are Type 2
lapses in care.
Pinckneyville Correctional Center

Patient 34
The patient was a 26-year-old man with a history of asthma who, according to the IDOC Death
Summary, died on 9/10/13 apparently from an acute asthma attack. (There was no information in
the medical record after 8/29/13.) There were significant deviations from the standard of care.
1. The patient had entered STA on 2/11/13. The only documentation from intake is a copy of
the patients problem list noting that he had a history of intermittent asthma. There is no
documentation of a history or physical examination being done. There is no further
documentation from STA. On 4/20/13, the patient was transferred to Vandalia. The transfer
summary noted that the patient used a rescue inhaler every four hours as needed for his
asthma. A physician saw the patient on 5/8/13 for his baseline asthma assessment. The
physician noted that the patient had daytime symptoms but did not specify what they were
or how often they occurred. On physical examination, the physician noted there was
expiratory wheezing. The physician also noted that the patient used his inhaler on an asneeded basis, but did not document the actual frequency of use. The physicians assessment
was that the patient had intermittent asthma. The physician ordered a rescue inhaler with
instructions for the patient to use it two times per day.
On 5/16/13, the patient was transferred to Du Quoin IIP. The nurse who performed the
reception screening noted that the patient used his rescue inhaler two times per day. A
physician saw the patient for chronic care of his asthma on 6/5/13 at Pinckneyville. The
physician noted that the patient did not have daytime or nighttime symptoms. The physician
documented that the patient used his rescue inhaler two times per day. The physicians
assessment was that the patient had intermittent asthma. On 8/29/13, a nurse saw the patient
for a cold. The nurse noted that the patient had had a runny nose and nasal congestion for
two days. On physical examination, the nurse noted that the patient had expiratory wheezes.
The nurse ordered an antihistamine and advised the patient to increase his fluid intake. The
nurse did not address the wheezing. This was the last entry in the patients medical record.
As noted above, he died on 9/10/13.
10
The documentation is not clear, but it appears that the patient was using his inhaler two
times per day. According to national guidelines, if the patient used his inhaler more than
two times per week, he had persistent, not intermittent, asthma and should have been treated
with inhaled corticosteroids. The failure to do so is a Type 2 lapse in care. The failure of
the nurse to address the patients wheezing on 8/29/13 is a Type 1 lapse in care. Either of
these lapses could have contributed to the patients death.
Patient 35
The patient was a 55-year-old man with a history of hypertension, diabetes, diabetic neuropathy
and a myocardial infarction with angioplasty in 1999 who died on 4/25/13 from a cardiac arrest.
There were significant deviations from the standard of care.
1. On 4/25/13, the patient suffered a cardiorespiratory arrest while in school. Custody staff
did not initiate CPR. If CPR had been initiated in a timelier manner, the patients death may
have been prevented. This is a Type 14 lapse in care.
2. On 7/1/12, a nurse saw the patient for a complaint of lower back pain and difficulty
urinating. The nurse performed a urinalysis which revealed increased ketones, bilirubin,
and protein. The tests for nitrite and leukocytes were negative. (When positive, these are
indicative of a possible urinary tract infection.) The nurse contacted a physician, who
ordered antibiotics for a urinary tract infection without evaluating the patient. The physician
also ordered observation in the infirmary for 23 hours. The physician did not order a urine
culture. The physician diagnosed and treated the patient for a urinary tract infection without
evaluating the patient and without any clear clinical indication that the patient had it. In
addition, the physician did not order a urine culture, which is standard of care when treating
a male patient for a presumed urinary tract infection. These are Type 1 lapses in care.
3. The physician saw the patient the following day, noted that he was feeling better and
discharged him from the infirmary. The physician ordered follow-up with another
urinalysis in one week. A physician did not see the patient until 7/23/12. This is a Type 3
lapse in care.
4. The urinalysis performed on 7/23/14 revealed that the ketones, protein, and bilirubin were
negative, and that the glucose was elevated. Based on this, the physician increased the
patients diabetes medications. (On 4/26/12, the patients hemoglobin A1c (7%) had
indicated that the patients diabetes was in good control.) On 9/6/12, a physician saw the
patient for chronic care and lowered the dosage of the patients diabetes medication. The
first physician increased the patients medication solely based on an abnormal urinalysis.
This is not consistent with the standard of care. This is a Type 2 lapse in care.
Patient 36
The patient is 59-year-old man with a history of hypertension, diabetes, metastatic prostate cancer
and aplastic anemia who died of a cardiac arrest on 4/30/13. There were significant deviations from
the standard of care.
11
1. Physicians saw the patient for chronic care on 3/12/12 and 11/19/12. They did not document
a history related to the patients hypertension. A physician saw the patient for chronic care
on 7/13/12 and checked the boxes indicating that the patient was complaining of a headache
and chest pain. The physician did not document any further history related to these
complaints. A physician saw the patient for chronic care on 3/22/13. He checked the boxes
noting that the patients symptoms were headaches and transient weakness. The physician
did not document any further history related to these complaints. These are Type 2 lapses.
Stateville Correctional Center

Patient 39
The patient was a 61-year-old man who had been incarcerated since 1979 and died at Stateville on
1/10/13 following an acute GI bleed secondary to varices from hepatitis C-related cirrhosis. He
also had liver cancer (HCC) which was listed as the cause of death on the death certificate. There
1. In January 2008, the patient saw hepatology at UIC regarding his hepatitis C and possible
treatment. There is no evidence that he ever followed up with UIC after the liver biopsy. It
is not clear why the patient did not receive hepatitis C treatment; the chart has conflicting
documentation on this issue. There is no documentation in the chart that treatment was
offered to the patient or discussed with him. Had he received treatment in 2008, his risk of
progressing to hepatic decompensation and HCC would have been significantly decreased.
2. At the May 2012 chronic care clinic, his weight was down 15# (to 180# from 195# in
January) but not acknowledged by the doctor. The PA saw him on 8/27 for ongoing weight
loss; by now he was down to 156#. She ordered a work up and referred the patient to the
Medical Director, who saw him in early September and ordered an ultrasound. On 9/25/12,
the ultrasound showed multiple liver masses. On 10/1/12, he was approved for GI consult
for liver biopsy. There were no records to indicate this was ever done. On 11/29/12, a CT
scan showed a liver mass suspicious for cancer. In early December 2012, he started to
decompensate with increasing ascites and worsening dyspnea on exertion. He was finally
sent to the outside hospital on 12/19, three months after his abnormal ultrasound. This is a
3. Generally poor chronic care is noted throughout the health record. The patient presented
with severely elevated blood pressure on numerous occasions, often greater than 200/100,
and each time was simply sent back to his cell with the instructions to take his medication.
Even the one time he was admitted to the infirmary, he was discharged the next day, prior
to gaining control of the blood pressure. This is a Type 2 lapse in care.
Patient 40
12
This was a 33-year-old HIV+ man who was received at Menard on 3/19/13, transferred to Stateville
on 5/13/13 and died on 8/12/13 of metastatic epithelial adenocarcinoma. There were significant
1. He gave a history of anal warts at his ID telemedicine visit in early April 2013 and was
referred to the facility doctor for this. The doctor at Menard saw him on 5/2/13 and
described severe anal condylomata with bleeding. He did not treat the patient, but ordered
only Motrin and told him to keep the area clean. This is a Type 1 lapse in care, as anal warts
(HPV) are a well-known cause of anal cancer in HIV + men.
2. After his transfer to Stateville, he saw the PA on 7/10/13 for nausea, vomiting and blood in
the stool. She examined him and noted moderate HPV and a large mass in the right
buttock measuring 4.5 x 4.5 cm. She questioned if he may have cancer (sarcoma) and
referred the patient to the Medical Director. He saw the doctor on 7/25, who noted the
patient had a mass in the perirectal area extending anteriorly into the right groin. He too
considered that the patient may have cancer, but rather than referring the patient for biopsy,
only ordered plain x-rays, pain medication and follow up in two weeks. This is also a Type
1 lapse in care.
3. One week later, he was brought to the HCU with pain in his chest, lower right side and right
thigh. He was seen by the PA, who referred him to the doctor, who noted lumps in both
groins and perianal area. He ordered admission to the infirmary for 23-hour observation.
The infirmary provider noted a large (14 x 8) indurated irregular fixed mass in the patients
right proximal thigh for two months and concluded it was an abscess. S/he ordered IV
fluids, pain medications and an antibiotic. He was not seen again by a provider while
admitted to the infirmary. This sequence of events encompasses several types of lapses.
Clearly there was no communication between the admitting provider and the infirmary
provider as to the reason for the admission and the suspicion of the referring doctor (Type
5 lapse). The infirmary physician also failed to recognize the significance of a rectal mass
in an HIV patient with a history of HPV (Type 1 lapse).
4. Two days later, on 8/3/13, the nurse was summoned to the patients room for uncontrolled
bleeding from the thigh mass. She applied a pressure dressing and notified the doctor. The
only order was to call again if there was further bleeding. The next morning, the LPN noted
that he was still bleeding. At 7:00 p.m., another nurse noted continued bleeding, having
soaked through three ABD pads and a diaper. The doctor was notified and told the nurse to
reinforce the pressure dressing. At 10:30 p.m., the nurse reassessed the patient and noted
that he had soaked through another three ABD pads and a diaper. She called the doctor again
and received an order to send him to the emergency department. He never returned to the
facility. He died a week later. This represents a Type 3 lapse in care, for allowing the patient
to remain in the infirmary with uncontrolled bleeding for two days, and also for failure to
refer the patient for appropriate work up and treatment from the time the condition was first
evident a month prior.
Patient 42
13
This was a 64-year-old man who died at Stateville of pneumonia on 7/31/13. He was chronically
housed in the infirmary for advanced dementia and had a feeding tube, Foley catheter and was
incontinent of stool. He also had a sacral wound which was not described further in the health
record, and the care of which was rarely documented. He was rarely seen by the doctor; only four
times between January and the date of death nearly eight months later. There were significant
1. In early June, the doctor was notified that the patient had a productive cough and low
oxygen level. He ordered an antibiotic, but did not evaluate the patient. When the symptoms
persisted, he ordered more of the same antibiotic and nebulizer treatments and saw the
patient on 6/6/13. A sputum culture obtained on 6/3/13 grew two organisms, one of which
was resistant to the chosen antibiotic, but no changes in therapy were made. This is a Type
4 lapse in care.
2. Over the next few weeks, the patient was intermittently described as having a cough
productive of thick, colored mucus, but no one notified the doctor of this for an entire
month. This is a Type 1 lapse in care.
3. On 7/1/13, the doctor was notified of the productive cough and ordered an antibiotic, but
did not evaluate the patient. On 7/9/13, the doctor saw the patient. His entire note consisted
of Not responsive. No change. Alzheimers Dementia. Continue same care. The patient
continued to cough up and require suctioning of thick, colored sputum. By 7/24, he is
described as having difficulty breathing and coughing up large amounts of thick green
mucus. His vital signs were rarely documented, but on 7/25/13 his temp was recorded at
101.2 with a respiratory rate of 22. The doctor was notified and ordered a CBC and
antibiotics for five days, but did not see the patient. These lapses are of a type not described
in the taxonomy structure; failure to evaluate a patient identified by nursing staff as
requiring medical attention.
4. The patient continued to decline. On 7/29/13, the doctor was contacted because the patient
was now febrile with a temp of 102.8, had a low oxygen saturation at 85%, large amounts
of thick yellow mucus on his face and chest and difficulty breathing. He ordered the patient
to be sent to the ED. The patient was returned to the facility the next evening at 10:30 p.m.
in an obviously unstable condition. He was requiring high flow oxygen via a non-rebreather
mask, had a low blood pressure of 95/60, and a rapid heart rate of 109. The doctor was
called twice for orders but did not respond. Five hours later, the patient was found dead in
his cell. This is a Type 5 lapse in care in that, one would hope that if the receiving physician
had been informed of the patients condition, he would not have accepted the patient back
to the infirmary in unstable condition. This is also a Type 3 lapse because the patient had
clinically obvious pneumonia for two months before he was referred to the hospital.
Hill Correctional Center

Patient 43
14
This was a 48-year-old man who was admitted to IDOC in 1984, arrived at HCC in 2009 having
quit smoking two years prior and died of lung cancer on 1/30/13. There were multiple serious
1. The first nurse sick call note is dated 5/8/12, when he stated, I coughed up blood and its
from this injury to my shoulder. He saw the doctor on 5/15. He had lost 30 pounds over
the past year. The doctor ordered labs, an anti-inflammatory and a follow-up in two weeks,
but did not order a chest x-ray to work up the hemoptysis. This is a Type 1 lapse in care.
2. When the doctor saw the patient back on 6/5, the patient complained of left-sided chest
pain radiating down the left arm, weight loss, and spitting up thick sputum. On exam the
doctor noted an enlarged supraclavicular lymph node. He reviewed and acknowledged that
the labs revealed anemia. He put the patient on iron and ordered a chest x-ray and a followup visit. The chest x-ray was done that day and showed, A focal opacity in the left lower
lobe with tenting of the left hemi-diaphragm. This finding is new...superimposed acute
infection cannot be excluded... follow up may be obtained. On 6/13, the Medical Director
saw the patient in follow up of the chest x-ray results. He noted that the patient had
multiple complaints but did not enumerate them. He ordered the patient saline gargles
and a repeat CBC after 30 days, then follow-up. He did not acknowledge the abnormal
chest x-ray, nor arrange for further investigation. This is a Type 4 lapse in care.
3. On 7/17, the Medical Director saw the patient in follow up of the CBC. His weight was
now 130 pounds. The anemia was slightly worse. The doctor increased the iron, ordered an
HIV test and a repeat chest x-ray in December, but did nothing to work up the weight loss
and anemia. This is a Type 1 lapse in care.
4. The patient began submitting grievances stating that he believed he might have cancer and
should be referred to a specialist for appropriate diagnosis and treatment. There is no
evidence that these requests were acted upon. On 8/15, the patient was brought to the clinic
to see the Medical Director. He reported spitting up blood since 6/17, chest pain since
February, hoarseness x 3 months, pain in the left scapular area, and coughing a lot since
May. His weight was now 127 pounds. The doctor noted an enlarged lymph node on exam
but only ordered more labs and a Z-pack as well as an x-ray of the abdomen. This is a Type
1 lapse in care.
5. On 8/20, he presented with hemoptysis and brought a tissue with large amount of blood in
it. The nurse noted his voice had a harsh tone. She referred him to the doctor immediately.
The only subjective information the doctor documented was, Says I am better than before.
He documented a normal exam, and his assessment was follow up hemoptysis. The plan
was to arrange blood results, will follow up accordingly. The labs ordered on 8/15 were
drawn now and showed worsening anemia. This is another Type 1 lapse.
15
6. On 8/21, he presented to the nurse at 9:00 p.m. with left shoulder and chest pain. She placed
him in the infirmary for observation. The RN saw the patient at 3:00 a.m. and noted that
the patient rated his pain as extreme and that his left shoulder blade appeared different.
The Medical Director saw the patient on 8/22 and noted that the patient Says I am fine, I
have this left shoulder pain off and on for 1-2 months. He documented a normal exam and
discharged the patient back to the unit with naproxen and follow up as needed. Another
Type 1 lapse.
7. On 8/29, the patient was brought to the HCU in a wheelchair because the pain in his left
side was so severe he was unable to walk upright. The nurse noted that his physique is
asymmetrical, veins, muscle more pronounced on left side...skeletal more pronounced on
left side...I/M states he coughed up blood. The Medical Director saw him the next day and
noted the left cervical adenopathy and now new left axillary adenopathy. He ordered a
repeat chest x-ray, sputum cytology and discussed the case with Dr. Baker on an emergency
basis to get approval for a CT scan. He also spoke to a pulmonologist to arrange
consultation. The patient was placed in the infirmary.
The CT scan was done the next day (8/31) and showed massive involvement of the thoracic
structures with a tumor which had wrapped itself around the patients heart and major
arteries as well as the major airways.
The CT report was received by the institution on 9/4 and discussed with the patient the
same day. He was seen by pulmonology on 9/5, but clearly his case was too far advanced
for anything other than palliative treatment. He continued to decline until he died four
months later. There is no category of lapse to describe the overall apathy to the symptoms
of serious disease in this patient.
Patient 44
This was a 71-year-old man who was received in IDOC in 2000 and died of metastatic pancreatic
cancer at HCC on 5/15/10. There were significant deviations from the standard of care.
1. He was admitted to the infirmary on 2/13/10 with a one week history of nausea, vomiting,
weakness and upper abdominal discomfort. His weight was 125#. No work-up was ordered
by the doctor at the time of admission. On 2/16/10, the PA saw the patient and ordered labs
and a chest x-ray, which showed a moderate left pleural effusion which the PA read as
consolidation. She concluded he probably had pneumonia despite the lack of fever, cough,
or respiratory symptoms, and put him on Cipro, which is not the appropriate treatment for
pneumonia. This is a Type 1 lapse in care.
2. Over the next five weeks, the patient hardly ate and subsisted mostly on soup. His weight
dwindled down to 112#, yet during the few doctor visits, no further work-up was
documented, nor was there further mention of his supposed pneumonia and pleural
effusion. This is another Type 1 lapse in care. Finally on 3/21/10, another chest x-ray was
ordered and showed an increase in the size of the pleural effusion. A CT scan was obtained
and the patient was admitted to the hospital, where he was found to have metastatic
pancreatic cancer.
16
Patient 45
This was a 48-year-old man with dyslipidemia who had sudden cardiac death on 9/21/10. There
1. He first presented on 8/12/10 with 9/10 midsternal chest pain and was seen by a nurse, who
elicited a family history of heart disease. She performed an ECG which was abnormal,
showing ST depression in the lateral leads. She decided the patient had indigestion, gave
him Maalox and did not refer him to a provider. These are Type 1 and Type 10 lapses in
care.
2. On 8/26/10, he saw the PA for chest pain, which he reported was occurring approximately
every other day since June 2010. She noted that his recent ECG was unchanged from priors
and concluded he had GERD vs pleurisy, treated him with antacids and Motrin and
requested follow up in four weeks. His Framingham risk at this time was moderate at 15%,
though she did not calculate it. This is a Type 1 lapse.
3. On 9/21/10, he was found down in his cell. CPR was initiated but the patient died. Coronary
atherosclerosis was the cause of death on the autopsy summary. He was not on a statin,
aspirin, nitroglycerin or beta blocker at the time of his death. This is a Type 2 lapse in care.
Patient 46
This was a 56-year-old man who was admitted to IDOC on 10/12/11, transferred to HCC on
11/9/11 and died of non-Hodgkins lymphoma on 9/9/13. He had elevated liver enzymes on
reception labs, but these were not worked up. He had no known chronic diseases and so was not
followed in the chronic care program.
1. He was seen episodically until 1/29/13, when he presented to sick call with left-sided
abdominal pain and was found to have marked enlargement of his spleen. The doctor did
not order imaging, only urine and blood tests. He told the patient to drink more water and
ordered naproxen. This is a Type 1 lapse in care.
2. The CMP showed a markedly elevated bilirubin at 7.7 and mildly elevated AST at 90. This
lab was signed off by the doctor but not acted upon and there was no follow-up of this. This
is a Type 4 lapse.
3. The patient presented again on 5/7 with ongoing left-sided abdominal pain. He was
referred to MDSC the next day and was seen by the nurse practitioner, who performed a
thorough history and physical exam. She ordered abdominal films and an evaluation by
the Medical Director. The films were taken on 5/8 and read 5/10 as, Soft tissue density
mass noted in the left abdomen may be related to marked splenomegaly. There is also
possible hepatomegaly... A CT or ultrasound was suggested. An ultrasound was done on
5/30 and faxed to the institution on 6/5. It showed marked splenomegaly and CT was
suggested for better detail. This recommendation was never followed. This is a Type 4
lapse in care.
17
4. On 6/20, the patient saw the Medical Director, who documented that the patient stated,
Doc, I am much better. My pain is better, my health is getting better... Again, his marked
splenomegaly was noted, but no further work-up or intervention was planned aside from
evaluation in the hepatitis C clinic. This is a Type 1 lapse in care because while liver
disease can cause enlargement of the spleen, there are only a few conditions that cause this
degree of massive enlargement, with malignancy being the most common cause.
5. The patient was not seen again until two months later on 8/27, when the nurse saw him for
abdominal pain, rated 8/10 with dyspnea on exertion, nocturnal cough and epistaxis. The
patient was hypoxic, unable to stand and his abdomen was obviously distended. She put
him on four liters of oxygen and referred the patient to the doctor who saw him that day,
admitted him to the infirmary and placed him on antibiotics. A chest x-ray showed right
middle lobe and left lower lobe consolidations. His oxygen requirements continued to
increase until he was on 10 liters by non-rebreather mask and satting in the upper 80s. He
was clearly not getting better, yet he was kept in the infirmary rather than sent to the ER,
as would have been appropriate. This is a Type 3 lapse in care.
6. Finally on 8/31, the RN in the infirmary clearly had concerns about the patient. She called
the Medical Director who advised that the oxygen be decreased. Recognizing the
inappropriateness of this order, she then contacted the HCUA and the Wexford Medical
Director, who contacted the Facility Medical Director. The Facility Medical Director then
called and ordered the oxygen to be increased back to 10 liters non-rebreather and to send
the patient out if his oxygen sat went below 85%, which it did that afternoon. He was
transferred to Cottage Hospital, where he was admitted to the ICU in critical condition and
was found to have non-Hodgkins lymphoma with widespread adenopathy. His condition
rapidly deteriorated until he died less than two weeks later.
Centralia Correctional Center

Patient 50
This was a 56-year-old man who died of metastatic renal cell cancer on 3/22/13. There were
1. He first reported painless blood in his urine on 7/15/12. His UA showed blood, protein and
WBCs. He saw the doctor the next day, who diagnosed a UTI and treated him with an
antibiotic. It does not appear that the urine was cultured. His weight at this visit was 173#,
down from 185# four months earlier. The weight loss was not commented upon. The doctor
requested follow up in one week with repeat urinalysis. One week later, the urine still
showed blood and the doctor continued the antibiotic and requested follow up in another
week. Again there are no culture results to correspond to the UA. On 7/28/12, the doctor
saw him again. The patient was still having painless hematuria. The doctor ordered another
urinalysis with culture. He was scheduled for follow up on 8/4/12, but this MD line was
marked as cancelled because he had been seen on the 28th.
18
These are Type 1 lapses in care; a 56-year-old man with painless hematuria and weight loss
has urological cancer until proven otherwise. UTIs in men are uncommon in the absence of
a precipitating factor such as catheterization, instrumentation, or bladder outlet obstruction.
This patient should have had the appropriate work-up at this juncture.
2. Three months later, on 10/23/12, he presented to the nurse with right testicular pain for three
weeks. A urine dip showed only blood and protein. He saw the doctor the next day, and was
diagnosed with acute epididymitis and treated with Cipro. The urine was not cultured. He
now weighed 166#, but again the weight loss appears to have gone unnoticed. A 10-day
follow-up was requested. He was seen on 11/1 and still had pain. No change in treatment or
further work-up was ordered. These are Type 1 lapses, as the clinical scenario did not support
the diagnosis of epididymitis, and he was not ordered the appropriate work-up or treatment
for this condition, even if it was the correct diagnosis. Meanwhile, the persistent hematuria
and ongoing weight loss were not addressed.
3. Of note, the patient was frequently hypertensive during clinic visits with many systolic
blood pressure readings in the 140s and 150s, yet these were not addressed and there were
no chronic care notes. These are Type 2 lapses in care.
4. Over the next three months, the patient was seen multiple times for ongoing testicular pain.
An ultrasound showed only a varicocele. All the while his weight loss continued. On 2/7/13,
he saw the doctor for ongoing groin and testicular pain. His weight was now 158#. The
doctor decided he had a chronic varicocele and ordered ibuprofen. On 2/15/13, he was back
on MD line for testicular pain, at which time he reported weight loss and bloody urination.
He had a palpable abdominal mass on exam. The doctor ordered a work-up which
ultimately revealed an unstable aortic aneurysm with possible penetrating atherosclerotic
ulcer and a renal mass as well as multiple liver lesions. These delays represent Type 1 lapses
in care.
The patient was held in the infirmary, then transferred to the local hospital on 3/7/13 after
discussion with a local vascular surgeon. Hospital records are limited but he evidently
underwent biopsy of the pelvic mass which confirmed metastatic renal cancer. He was
deemed not to be a surgical candidate for AAA repair based on this and subsequently chose
a nonaggressive approach to his management and died two weeks later. Had the hematuria
been worked up appropriately when he initially presented eight months earlier, the cancer
may have been diagnosed at a stage more amenable to treatment.
Patient 52
This was a 79-year-old man who was chronically housed in the Centralia infirmary and died rather
abruptly on 3/26/13. There were significant deviations from the standard of care.
1. He had a history of BPH, CHF and a cardiac arrhythmia which is not described further in
the record; however, the only problem ever mentioned in the chart notes is BPH. He almost
certainly had prostate cancer, considering that his PSA was 49 in February 2013,
19
but this too was never mentioned in the chart. The failure to monitor and treat his chronic
illnesses are Type 2 lapses in care.
2. He was in his usual state of health up through 3/22/13 judging by the nursesbrief notes.
Then, at the time of his next assessment on 3/25/13 at 6:20 p.m., he was noted to be short
of breath, with a thready pulse of 130, blood pressure of 130/77 and hypoxic with an oxygen
saturation of 72% on room air. His color was described as ashen and his lungs had rales in
the bases bilaterally. There was no fever or cough. The doctor was called and ordered
oxygen, a chest x-ray and an antibiotic but did not send him to the hospital. This is a Type
3 lapse in care.
3. By 7:40 p.m., he was satting only 80% on 5 liters and so was switched to a non-rebreather
mask at 9 liters in order to get his oxygen saturation to 91%. There was no evidence the
nurse called the doctor for this order. This is a Type 10 lapse in care.
4. At 11:15 p.m., he was no better; still the doctor was not called. At 12:45 a.m., he fell coming
out of the bathroom. His heart rate was 144, oxygen sat was 84% and he was described as
pale with labored respirations. The nurse put him back to bed and increased the oxygen to
10 liters but did not call the doctor. This is a Type 1 lapse.
5. At 4:20 a.m., he coded and was finally sent out emergently with CPR in progress. Needless
to say, he did not survive.
Illinois River Correctional Center

Patient 54
This was a 55-year-old man with a history of hepatitis C, hypothyroidism and bipolar disorder who
was admitted to IDOC through NRC on 10/25/12, transferred to IRCC on 11/20/12, and died of
complications of metastatic lung cancer on 6/14/13. He had a greater than 40 pack-year smoking
history and a strong family history of lung cancer, with his mother and two sisters dying of the
disease. His course contained significant deviations from the standard of care
1. On the day after his arrival, 11/21/12, he was seen by the RN for spitting up blood. The
patient showed the nurse a quarter-sized amount of blood sitting on paper towel. The nurse
gave the patient a container and instructed him to call if there was any increase in
hemoptysis. He was not referred to a provider. This is a Type 1 lapse in care.
2. Later that evening, the same nurse documented that the patient had a quarter-sized amount
of bloody sputum in the specimen cup. Her assessment was hemoptysis, and the plan was
continue to observe. Again the patient was not referred to a provider. This is another Type
1 lapse.
3. On 11/25/12, the patient saw the LPN for a dressing change of his foot and showed the
nurse tissues containing bloody sputum. He was referred to MDSC the next day. On
11/26/12, the physician saw the patient, who reported intermittent hemoptysis and right
20
sided pleuritic chest pain. She ordered a chest x-ray, sputum and blood work. The chest xray was done on 11/30/12 and showed, Focal opacity projected over the right lateral upper
lung zone. Recommend follow up chest CT to exclude a lung mass. The report was signed
on 12/3/12 by the ordering physician but not acted upon; no further work-up was pursued.
4. On 2/7/13, the doctor saw the patient in chronic care clinic. He complained of chest
tightness in the upper chest. She ordered a chest x-ray in one week, which showed the
interval development of right upper lobe opacity seen extending from the hilum to the
right lung apex, new since prior study...right upper lobe opacity appears to be related to
upper lobe collapse with elevation of the right minor fissure. This may be related to a right
hilar/suprahilar neoplasm. Further evaluation with CT of the chest is recommended. The
report was signed by the physician on 2/19/13 but again, not acted upon. This is another
Type 4 lapse.
5. On 2/28/13, the patient presented to nurse sick call requesting his x-ray results. He was
referred to the physician and seen on 3/1/13 at hepatitis C chronic care clinic. He
complained of ongoing chest tightness. There is no mention of the abnormal chest x-ray
that she previously signed. Her plan was to repeat the chest x-ray and see the patient again
when the x-ray results were back. Again, a Type 4 lapse.
6. On 3/5/13, the x-ray was repeated and again showed the right upper lobe opacity with
collapse and again a CT was recommended. This time the doctor finally did acknowledge
the abnormal findings when she saw the patient on 3/8/13, and referred him (non-urgently)
for a CT of the chest. Meanwhile, on 3/23/13, he presented with pain in the right collar
bone. An x-ray showed a pathologic fracture of the right clavicle. The patient was admitted
to the infirmary.
7. On 4/9/13, the CT showed a 3 cm right upper lobe lung mass occluding the right upper lobe
bronchus with enlarged mediastinal lymph nodes and a lytic lesion of the right clavicle. On
5/8/13, he underwent biopsy of the right clavicle which confirmed metastatic non-small cell
lung cancer. He was seen by oncology on 6/5/13, who recommended palliative radiation
treatment, which the patient declined. He died nine days later. Had this patient undergone
timely work-up when he initially presented seven months earlier, it would likely have
significantly prolonged his life.
Patient 55
This was a 40-year-old man who died on 1/23/14 of metastatic rectal cancer. He was first admitted
to IDOC in 2000. He first began complaining of constipation in January 2011, at which time his
weight was 195#. He was not referred to the doctor at that time. He returned with the same
complaint in May 2011 and had lost 10 pounds. He saw the physician for constipation and
abdominal pain that was worse with sitting, and urinary symptoms. He denied blood in the stool.
The doctor examined his abdomen but did not do a rectal exam. An abdominal x-ray and labs were
normal.
21
1. On 12/22/11, he presented to the LPN stating something is wrong and that he was losing
weight. He was now down to 158#. He saw the doctor, who did a rectal exam, found no
masses and no blood in the stool. She ordered more labs and follow up in one month. Blood
drawn on 12/30/11 showed mild iron deficiency anemia. The doctor ordered stool cards.
These came back positive in February and he was referred for colonoscopy, which was
performed on 4/13/12 and showed a large tumor in the rectum. Pathology showed invasive
adenocarcinoma. Although his care proceeded in a timely and appropriate manner from this
point on, his disease continued to progress and after a long and complicated course, he
ultimately succumbed. Given his constellation of symptoms, colonoscopy should have been
obtained timely after the anemia was identified, rather than 3 1/2 months later. This is a
Menard Correctional Center

Patient 56
This was a 63-year-old man who entered IDOC in 2007 and died on 2/11/14 of complications
following several cardiac arrests. There were significant deviations from the standard of care.
1. He had no known cardiac risk factors upon intake. He was found to have hypertension in
2011, but blood pressure checks were discontinued by the MD with follow-up as needed.
He was not started on medication. Likewise, he had an unfavorable lipid profile at that time
but this was not treated either. His Framingham risk at this time was high at 25%. These
are Type 2 lapses in care.
2. In September 2013, he presented with chest pain, shortness of breath and hypertension
(blood pressure 180/120, 190/120). He was given a dose of clonidine and placed in the
infirmary for observation. The admitting nurse obtained a history of orthopnea. The
Medical Director saw the patient that morning and noted that he had no complaints, but the
patient was tachycardic with a heart rate of 130. No ECG was ordered. In fact, no other
work-up or treatment was provided. He was discharged to his cell that afternoon with no
specific follow-up ordered. This is a Type 1 lapse in care. It is not appropriate to treat a
hypertensive urgency in a prison infirmary; such patients should be managed in a hospital
setting.
3. He presented on several more occasions with chest pain, shortness of breath and orthopnea
and was treated for pneumonia and anxiety. Finally, he was sent to the ER on 1/31/14 with
shortness of breath and was admitted with heart failure. He subsequently suffered several
cardiac arrests and ultimately died.
Patient 57
This was a 62-year-old man who was admitted to IDOC in 2008 and died on 11/16/13 of GI
bleeding from ruptured esophageal varices due to cirrhosis. He had a history of decompensated
cirrhosis and prior GI bleeding in 2007. There were significant deviations from the standard of
care.
22
1. He presented on 11/13/13 with severe lethargy, dizziness, dyspnea, melena x 2 days. He

was tachycardic with a heart rate of 104, blood pressure was 124/74 and had grossly bloody
stools on exam. The doctor ordered labs and placed him in the infirmary at 1:10 p.m. At
1:30 p.m., the admitting RN described him as pale and pastie (sic). He had a small black
stool. He complained of mild abdominal and chest pain. His blood pressure was 112/70 and
heart rate was 100. His hemoglobin (Hb) was 10.2 g/dL, down from 13.3 in July. This is a
Type 1 lapse in care. It is not appropriate to put a high-risk patient with active GI bleeding
in a prison infirmary.
2. At 4:00 p.m., his blood pressure was 110/62, pulse 80 and he was described as weak and
tired. At 8:00 p.m., a stat CBC was drawn per the doctors order. It was resulted at 9:13
p.m. and the Hb was down to 7.6 g/dL. At 9:45 p.m., the nurse called the doctor regarding
these results and he ordered only IV fluids. This is another Type 1 lapse. This dramatic drop
in the hemoglobin indicates that this patient is bleeding briskly.
3. On 11/14/13 at 3:25 a.m., his blood pressure was 100/60, pulse 104. At 9:20 a.m., the doctor
saw the patient, who reported weakness, dizziness and ongoing melanotic stool. He sent the
patient to the local hospital where he died two days later.
Patient 58
This was a 66-year-old man with multiple medical problems including diabetes, COPD and
coronary artery disease with history of 5 vessel CABG in 2009 who was received in IDOC in 2006
and died on 4/7/13 of metastatic renal cell carcinoma. There were significant deviations from the
standard of care.
1. He first presented on 11/12/12 with difficulty breathing, especially when lying down. He
saw the Medical Director the next day and was admitted to the infirmary for a CHF
exacerbation. A chest x-ray performed on 11/13/12 showed pulmonary vascular congestion
as well as nodular densities within the lungs bilaterally of which findings are suspicious
for neoplastic-metastatic disease, a finding which escaped the attention of the doctor when
he reviewed the film on the date it was taken. The patient was discharged back to his cell
on 11/15/12. This is a Type 4 lapse in care.
2. The film was read on 11/15 and received by the institution on 11/26, at which time the same
doctor signed the report and marked it file (rather than pull chart or see patient ). On
11/30/12, the doctor saw the patient in follow up of his infirmary admission, noted that his
symptoms were improved, but did not review the x-ray result with the patient or make any
reference to it. These are also Type 4 lapses.
3. On 12/10/12, the patient was referred to the Medical Director with shortness of breath and
chest tightness. The doctor noted that the patients symptoms were now resolved. He
concluded CHF, multiple medical problems, made no changes and returned the patient
to his cell. This is a Type 1 lapse in care.
On 1/16/13, the patient was brought to the HCU via wheelchair with complaints of chest pain
radiating down his left arm and shortness of breath. He was hypertensive and diaphoretic. The
23
nurse got a verbal order to send the patient to the ED, where he was found to have metastatic renal
cell cancer. He ultimately opted for palliative care and expired three months later.
Patient 59
This was a 64-year-old man who was severely beaten by his cellie on 1/24/13, resulting in massive
head injuries. He returned to the institution on 1/31/13. There were significant deviations from the
standard of care.
1. Over the ensuing three weeks, the patient was described with increasing disdain as being
uncooperative and unwilling to participate in self-care. His behavior became increasingly
problematic in that he ultimately began smearing feces in his room, disrobing and urinating
on himself. He was diagnosed with psychosis secondary to head injury and started on
psychotropics. He developed difficulty swallowing and let medication and liquids spill out
of his mouth. He continued to receive his usual medications including oral diabetes
medications. There was no record of his blood glucose being checked. This is a Type 2
lapse in care.
2. On 2/25/13, he was noted to be very sedated and slow to respond. His blood pressure was
78/40 and blood glucose was 54. The doctor saw the patient at 7:50 a.m, and described him
as lethargic and non-verbal; he had a flexion response to pain. Rather than send this unstable
patient to the hospital, the doctor ordered IV fluids and monitoring of vital signs. This is a
At 9:30 a.m., the blood pressure improved to 110/50. There are no further measurements of blood
glucose. At 10:45 a.m., he coded and died. The autopsy report listed the final cause of death as
blunt trauma to head aggravating hypertensive and arteriosclerotic cardiovascular disease and
diabetes mellitus.
Pontiac Correctional Center

Patient 62
This was a 42-year-old man who died of a glioblastoma multiforme on 4/16/13. The tumor was
first diagnosed in 2009, prior to his incarceration. He underwent excision in March 2009, and again
in September 2010 for recurrence. He was admitted to IDOC in July 2012. He had a restaging MRI
in October 2012 which showed no recurrence and his maintenance chemotherapy was
discontinued. Thereafter there was a significant deviation from the standard of care.
1. A subsequent MRI on 2/1/13 showed recurrence of a low grade enhancing mass in his left
temporal lobe. He was referred to neurosurgery but not scheduled for two months (4/10/13).
On 4/1/13, he was found with altered consciousness and stroke-like symptoms. He was taken to St.
James hospital, where CT showed significant edema around the mass and a 1 cm midline shift. He
was transferred to UIC, where it was decided that the risks of surgery outweighed the benefits. The
family decided to withdraw care on 4/15/13, and the patient died the next day.
24
C as e s witho u t Laps e s in C are

Dixon
Patient 1
Patient 3
Patient 5
Patient 13
Patient 15
Patient 20
Big Muddy
Patient 22
Patient 23
Patient 26
Patient 27
Patient 29
Graham
Patient 30
Shawnee
Patient 32
Pinckneyville
Patient 33
Patient 37
Vienna
Patient 38
Stateville
Patient 41
Hill
Patient 47
Patient 48
25
Centralia
Patient 49
Patient 51
Patient 53
Menard
Patient 60
Patient 61
Pontiac
Patient 63
26
A ppe nd ix 1
Taxo no m y fo r M o rtality R e vie ws
Lapse in Care In the judgment of the reviewers, a clinician has committed a significant
departure from the standard of care that a reasonable and competent clinician would not have
committed under the same or similar circumstances.
The 14 categories of lapse are:
Type 1 Failure to recognize, evaluate and manage important symptoms and signs so called
clinical red flags.
Type 2 Failure to follow clinical guidelines or standard of care for the management of chronic
diseases, such as hypertension, asthma, diabetes mellitus, hepatitis C infection, HIV/AIDS, chronic
pain, anticoagulation and care at the end of life.
Type 3 Delay in access to the appropriate level of care, of sufficient duration to result in a risk
of harm to the patient.
Type 4 Failure to identify and appropriately react to abnormal test results.
Type 5 Failure of appropriate communication between providers, especially at points where
transfers of care occur (care transitions).
Type 6 Fragmentation of care resulting from failure of an individual clinician or the primary care
team to assume responsibility for the patients care.
Type 7 Iatrogenic injury resulting from a surgical or procedural complication.
Type 8 Medication prescribing error, including failure to prescribe an indicated medication,
failure to do appropriate monitoring, or failure to recognize and avoid known drug interactions.
Type 9 Medication delivery error, including significant delay in a patient receiving medication
or a medication delivered to the wrong patient.
Type 10 Practicing outside the scope of ones professional capability (may apply to LVNs, RNs,
midlevel practitioners, or physicians).
Type 11 Failure to adequately supervise a midlevel practitioner, including failure to be readily
available for consultation or an administrative failure to provide for appropriate supervision.
Type 12 Failure to communicate effectively with the patient. Type
13 Patient non-adherence with suggestions for optimal care.
Type 14 Delay or failure in emergency response, including delay in activation or failure to follow
the emergency response protocol.
A ppe nd ix 2
D e ath R e vie ws
Patient Number
Patient #1
Patient #2
Patient #3
Patient #4
Patient #5
Patient #6
Patient #7
Patient #8
Patient #9
Patient #10
Patient #11
Patient #12
Patient #13
Patient #14
Patient #15
Patient #16
Patient #17
Patient #18
Patient #19
Patient #20
Patient #21
Patient #22
Patient #23
Patient #24
Patient #25
Patient #26
Patient #27
Patient #28
Patient #29
Patient #30
Patient #31
Patient #32
Patient #33
Patient #34
Patient #35
Patient #36
Patient #37
Patient #38
Inmate ID
[redacted]
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Institution
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Dixon
Big Muddy
Big Muddy
Big Muddy
Big Muddy
Big Muddy
Big Muddy
Big Muddy
Big Muddy
Graham
Lincoln
Shawnee
Pinckneyville
Pinckneyville
Pinckneyville
Pinckneyville
Taylorville
Vienna
Patient Number
Patient #39
Patient #40
Patient #41
Patient #42
Patient #43
Patient #44
Patient #45
Patient #46
Patient #47
Patient #48
Patient #49
Patient #50
Patient #51
Patient #52
Patient #53
Patient #54
Patient #55
Patient #56
Patient #57
Patient #58
Patient #59
Patient #60
Patient #61
Patient #62
Patient #63
Inmate ID
[redacted]
Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
Institution
Stateville
Stateville
Stateville
Stateville
Hill
Hill
Hill
Hill
Hill
Hill
Centralia
Centralia
Centralia
Centralia
Centralia
Illinois River
Illinois River
Menard
Menard
Menard
Menard
Menard
Menard
Pontiac
Pontiac
A ppe nd ix 3
Inte rnalM & M R e vie ws
Stateville patient 39
Hill patient 43
Hill patient 44
Hill patient 45
Hill patient 46
Illinois River patient 54
Centralia patient 52
Centralia patient 50
Menard patient 56
Menard patient 57
Menard patient 58
Menard patient 59 Big
Muddy patient 25 Big
Muddy patient 28
Pinckneyville patient 34
Pinckneyville patient 35
Lincoln patient 31

Final Report of The Court Appointed Expert: Lippert vs. Godinez

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Final Report of The Court Appointed Expert: Lippert vs. Godinez

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Case: 1:10-cv-04603 Document #: 339 Filed: 05/19/15 Page 1 of 405 PageID #:3155

Final Report of the Court Appointed Expert

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